Prioritas & Delegasi ala NCLEX: paket kilat

A patient is receiving continuous tube feeds. Which action best reduces the risk of aspiration?

1. ALay the patient flat for an hour after each bag is hung
2. BTurn the feed off only while the patient is asleep at night
3. CKeep the head of the bed raised to at least 30 degrees
4. DIncrease the feed rate so the stomach empties sooner

A patient on a cardiac monitor suddenly becomes unresponsive, and the monitor shows ventricular fibrillation. What is the priority once help has been called?

1. AGive an oral antiarrhythmic tablet and recheck the rhythm in five minutes
2. BDefibrillate as soon as the defibrillator is available, with CPR until then
3. CCheck the blood potassium level before any shock is considered
4. DRecord a full 12-lead ECG to confirm the rhythm before doing anything else at all

Saat membuka paket steril di atas meja, lipatan mana yang dibuka pertama?

1. ALipatan samping mana pun yang paling mudah dijangkau
2. BSemua lipatan sekaligus
3. CLipatan yang paling jauh dari perawat
4. DLipatan yang paling dekat dengan perawat

Seorang pasien dengan implan radioaktif tersegel melaporkan bahwa implan jatuh ke tempat tidur. Apa yang harus dilakukan perawat?

1. AMembiarkannya di tempat tidur sampai tim radiasi tiba besok
2. BMenggunakan forsep bergagang panjang untuk menempatkannya di wadah timbal
3. CMengambilnya dengan tangan bersarung tangan dan memasukkannya ke limbah klinis
4. DMeminta pasien memegangnya sampai bantuan tiba

A urine culture report states "mixed growth of three organisms, likely contamination." What is the nurse's best response?

1. AStart treatment for all three organisms with three antibiotics
2. BDiscard the report, because a mixed growth is always normal
3. CRecord the result as a confirmed urinary tract infection
4. DInform the provider and arrange a new, correctly collected sample

A patient with severe sepsis is oozing blood from IV sites. Platelets 40 × 10³/µL, fibrinogen low, D-dimer very high, PT and aPTT both prolonged. Which condition fits best?

1. AHemophilia A (factor VIII deficiency)
2. BImmune thrombocytopenic purpura (ITP)
3. CDisseminated intravascular coagulation (DIC)
4. DHeparin-induced thrombocytopenia (HIT)

Which side effect is common when a patient starts taking metformin?

1. ASevere headache
2. BNausea, abdominal discomfort or diarrhoea
3. CHypoglycaemia in most patients who take it
4. DRapid weight gain

A patient has a full-thickness burn all the way round the forearm. Which complication must be watched for closely?

1. AExcessive bleeding from the burn surface needing an urgent blood transfusion
2. BLoss of circulation to the hand as swelling builds under tight burned skin
3. CHypoglycaemia caused by the body using glucose to heal the burn
4. DDelayed hair growth on the arm

After coronary artery bypass surgery through a median sternotomy, which instruction is usually given for the first several weeks?

1. AAvoid heavy lifting and pushing up with the arms
2. BAvoid walking until the stitches are removed
3. CSleep only on the stomach to protect the wound
4. DLift the arms above the head often to stretch the chest

A one-way speaking valve is fitted to a patient's tracheostomy tube while the cuff is still inflated. What is the danger?

1. AThe patient will speak too loudly
2. BThere is no danger, as the valve works with any cuff
3. CThe patient cannot breathe out and may suffocate
4. DThe valve will humidify the air too much

Seorang pasien mengalami hemianopia homonim setelah stroke. Bagaimana perawat membantu pada awalnya?

1. AMenaruh bel panggil dan minuman di sisi tanpa penglihatan, untuk melatihnya
2. BMendekati dari sisi yang dapat melihat dan mengajarkan menoleh untuk memindai
3. CMenjaga ruangan gelap untuk mengurangi rangsangan visual
4. DMenutup mata pada sisi yang terkena dengan penutup

The nurse has four neurology patients. Which one needs to be seen first?

1. AA patient with a headache after a lumbar puncture this morning
2. BA patient with Parkinson's disease whose next dose is due in one hour
3. CA patient with multiple sclerosis who is tired after physiotherapy
4. DA patient with Guillain–Barré syndrome whose vital capacity is falling

How is an uncomplicated sigmoid volvulus often first treated?

1. AHigh-dose laxatives taken by mouth
2. BA barium meal given by mouth to untwist the bowel slowly
3. CDecompression with a flexible sigmoidoscope and flatus tube
4. DEating a large high-fibre meal

A patient on warfarin has a major upper GI bleed with an INR of 5. Which treatment should the nurse anticipate to reverse the warfarin?

1. AOral aspirin to balance the clotting system quickly
2. BProthrombin complex concentrate with IV vitamin K
3. CProtamine sulfate on its own
4. DMore warfarin to stabilise the INR