Prioritas & Delegasi ala NCLEX: paket kilat

An Rh-negative mother has just given birth to an Rh-positive baby. What does the nurse expect to give the mother?

1. ANo treatment is needed
2. BVitamin K to the mother
3. CA dose of the hepatitis B vaccine instead
4. DRh immunoglobulin within 72 hours

A toddler with tetralogy of Fallot becomes very blue and breathless while crying. What should the nurse do first?

1. AGive a large drink of water to calm the child
2. BPlace the child in a knee-to-chest position
3. CLay the child flat on their back
4. DEncourage the child to keep crying to open the lungs

A patient is on suicide precautions. Which room safety measure is appropriate?

1. ALet the patient keep a personal razor for shaving, as long as staff are told
2. BRemove items that could be used for self-harm, such as belts and cords
3. CKeep the door closed at all times so the patient has privacy
4. DAllow glass bottles if the patient seems calm

A patient’s white cell differential shows a raised number of band (immature) neutrophils, called a “shift to the left”. What does this usually suggest?

1. AA long-standing parasitic infection
2. BAn allergic reaction
3. CAn acute bacterial infection
4. DA typical viral infection

How should a blood sample for serum ammonia be handled?

1. APlaced on ice and sent to the laboratory at once
2. BLeft at room temperature for several hours first
3. CShaken firmly to mix it before it is sent away
4. DKept warm and sent with the next routine batch

A patient with long-standing rheumatoid arthritis has a hemoglobin of 10,5 g/dL (105 g/L), a low serum iron, a low total iron-binding capacity (TIBC) and a high-normal ferritin. Which condition fits best?

1. AAnemia of chronic disease (inflammation)
2. BAcute blood loss anemia
3. CIron-deficiency anemia
4. DVitamin B₁₂ deficiency anemia

A patient on the ward has shingles with open blisters. Which people are most at risk from contact?

1. AOnly people over 80 who have already had shingles themselves
2. BPregnant women and immunocompromised people who have not had chickenpox
3. CNo one, because shingles cannot spread
4. DPeople who have already had chickenpox in childhood and are now healthy

Why are liquid medicines for nasogastric tubes drawn up in dedicated enteral (oral) syringes rather than IV syringes?

1. AEnteral syringes measure doses less accurately
2. BEnteral syringes keep the medicine sterile
3. CIV syringes cannot hold liquid medicines
4. DTo prevent accidental intravenous administration

A patient with COPD is prescribed long-term oxygen therapy. How many hours a day is it usually needed to improve survival?

1. AAbout one hour each morning
2. BOnly when walking outside
3. COnly during meals
4. DAt least 15 hours a day

Seorang pasien yang memulai penghambat ACE kemarin mengalami pembengkakan bibir dan lidah serta suara serak. Apa yang harus dilakukan perawat pertama kali?

1. AMemberikan dosis berikutnya lebih awal, karena ini akan meredakan pembengkakan dengan cepat
2. BMengompres es pada bibir dan meninjau lagi besok pagi
3. CMengkaji jalan napas, meminta bantuan segera, dan menahan dosis berikutnya
4. DMenjelaskan bahwa ini adalah efek samping yang diharapkan dan tidak berbahaya

Why might a patient bleed more from the needle sites straight after haemodialysis?

1. ADialysis removes all the platelets from the blood
2. BThe fistula has been damaged and must be tied off
3. CHeparin is often used to stop the circuit from clotting
4. DDialysis raises the blood pressure sharply for several hours

Seorang lansia dengan diabetes tipe 2 memiliki glukosa 48 mmol/L, osmolalitas 365 mOsm/kg, tanpa keton bermakna, dan kebingungan. Apa prioritas pertama?

1. APembatasan cairan ketat untuk menghindari edema serebral
2. BBolus insulin IV besar untuk menormalkan glukosa dalam satu jam
3. CCairan IV yang hati-hati dengan pemeriksaan ketat osmolalitas, natrium, dan glukosa
4. DGlukosa oral untuk mencegah hipoglikemia selama pengobatan

A patient received IV morphine 20 minutes ago and the surgical consent form has not been signed. What should the nurse do?

1. ASign the form on the patient's behalf as a witness
2. BTell the surgeon, as the patient may not be able to consent now
3. CAsk the patient to sign quickly before they get sleepier
4. DAsk a relative to sign instead of the patient

Pada hari ke-6 setelah operasi abdomen, seorang pasien mengatakan ada sesuatu yang "terbuka" saat batuk, dan usus terlihat melalui luka. Apa yang harus segera dilakukan perawat?

1. AMendorong usus kembali dengan lembut dan merekatkan tepi luka dengan kuat
2. BMenutup dengan balutan steril basah salin, menekuk lutut, memanggil dokter bedah
3. CMemberi pasien makanan ringan untuk menenangkan sambil menunggu tim
4. DMembiarkan luka terbuka dan mendudukkan pasien tegak penuh di tempat tidur