Prioritas & Delegasi ala NCLEX: paket kilat

A nurse cannot read part of a medication order. What should the nurse do?

1. AGive the usual dose of the drug the nurse thinks was meant
2. BContact the prescriber to clarify the order before giving the drug
3. CAsk another nurse to guess what the order most likely says, then give it
4. DSkip the drug and not tell anyone until the next ward round

Seorang pasien setelah operasi besar memiliki keluaran urine 15 mL/jam selama dua jam, denyut jantung 115/menit, dan tangan dingin. Apa yang pertama kali dilakukan perawat?

1. AMenganjurkan pasien minum lebih banyak air dan memeriksa lagi nanti
2. BMembilas kateter dan memeriksa keluaran besok pagi
3. CMenunggu dua jam lagi untuk melihat apakah keluaran membaik
4. DMengkaji tanda-tanda syok, seperti perdarahan, dan melakukan eskalasi

A child has swallowed a button battery. Why is this urgent?

1. AIt always passes through the gut without harm
2. BThe only risk is poisoning from heavy metals years later
3. CIt is only harmful if several batteries are swallowed
4. DIt can burn through the lining of the esophagus within hours

Saat masuk rumah sakit, daftar obat dari rumah mencakup pengencer darah yang tidak ada dalam instruksi rumah sakit yang baru. Apa yang harus dilakukan perawat?

1. AMengabaikannya, karena instruksi rumah sakit menggantikan obat rumahan
2. BMengklarifikasi ketidaksesuaian dengan pemberi resep
3. CMenyuruh pasien diam-diam meminum persediaannya sendiri
4. DMemberikan dosis rumahan tanpa instruksi

Kumpulan temuan mana yang sesuai dengan hiperkalsemia?

1. AKonstipasi, kelelahan, kebingungan, dan batu ginjal
2. BTetani, kram otot, dan tanda Chvostek positif
3. CGelombang T runcing dan kelemahan otot saja
4. DHaus dengan urine sangat encer sebagai satu-satunya tanda

Hasil pasien mana yang harus dilaporkan perawat lebih dulu?

1. AGlukosa 42 mg/dL (2,3 mmol/L) pada pasien yang berkeringat dan bingung
2. BHbA1c 7,4% (57 mmol/mol) pada pasien diabetes tipe 2
3. CKreatinin 1,6 mg/dL (141 µmol/L) pada pasien PGK stabil yang sudah diketahui
4. DKolesterol total sedikit di atas target

Which finding with a groin hernia needs urgent surgical review?

1. AThe lump has been present for several years without pain
2. BThe lump has become painful and tender and cannot be pushed back
3. CThe lump disappears completely when the patient lies down flat
4. DThe lump gets bigger when the patient coughs

An older patient with delirium is trying to leave the ward at night, saying he must go home. What is the best initial approach?

1. AGive a sedative straight away without a prescription
2. BPhysically restrain him in bed until the morning so that he cannot fall
3. CCalmly reassure and redirect him while the team assesses his capacity and safety
4. DLet him leave, because adults can always do as they wish whatever their state

After a prescribed IV fluid bolus for hypotension, what should the nurse do next?

1. AStop all monitoring if the patient says they feel better
2. BReassess heart rate, blood pressure, urine output and lung sounds
3. CWait until the next routine observations in four hours
4. DStart a second fluid bolus straight away without checking anything

Seorang berusia 82 tahun dengan pneumonia komunitas baru mengalami kebingungan, dengan RR 32/menit, TD 88/52 mmHg, dan urea 9 mmol/L. Apa yang ditunjukkan hal ini?

1. ARespons normal terhadap infeksi pada lansia
2. BSkor CURB-65 sebesar 5: risiko tinggi yang membutuhkan tinjauan senior segera
3. CSkor CURB-65 sebesar 1: cocok untuk antibiotik oral di rumah
4. DSkor CURB-65 sebesar 3: hanya rawat inap rutin di bangsal umum

Which complication is a particular risk in nephrotic syndrome?

1. AVenous thrombosis
2. BHypoglycaemia
3. CBleeding from low platelets
4. DLow cholesterol

Dari pasien stroke iskemik akut berikut, siapa yang paling kecil kemungkinannya memenuhi syarat trombolisis IV?

1. APasien yang menjalani operasi abdomen besar lima hari lalu
2. BPasien yang CT scan-nya tidak menunjukkan tanda perdarahan intrakranial
3. CPasien dengan tekanan darah 170/95 mmHg
4. DPasien yang gejalanya dimulai 90 menit lalu

In the UK National Early Warning Score (NEWS2), what does an aggregate score of 5 or more usually trigger?

1. ARoutine observations once every 12 hours, with no other change in care
2. BNo change unless the patient complains
3. CAn urgent review by a clinician skilled in acute illness
4. DDischarge planning for the next day

A 76-year-old with a past peptic ulcer needs long-term anti-inflammatory treatment for arthritis. Which plan best reduces GI bleeding risk?

1. AConsider an alternative; if an NSAID is needed, add a PPI
2. BUse the highest NSAID dose to shorten the course
3. CCombine two different NSAIDs at lower doses
4. DTake the NSAID with a glass of milk instead of food