Prioritas & Delegasi ala NCLEX: paket kilat

A patient had a colostomy formed yesterday. Which stoma appearance should be reported straight away?

1. ADark purple or black
2. BSlightly swollen
3. CA little bleeding when cleaned
4. DMoist and pink-red

Which finding most suggests a tension pneumothorax rather than a simple pneumothorax?

1. AMild breathlessness with reduced breath sounds on one side of the chest only
2. BA small air leak seen on a routine chest X-ray
3. CTrachea shifted away from the affected side, with low blood pressure
4. DSharp chest pain that is worse on deep breathing

Mengapa obat cair oral diberikan dengan spuit oral atau enteral, bukan spuit IV standar?

1. ASpuit oral mengukur dosis intravena dengan lebih akurat
2. BSpuit oral tidak cocok dengan jalur IV, sehingga mencegah kesalahan rute
3. CSpuit IV tidak dapat mengukur volume kecil cairan oral dengan akurat
4. DTidak ada alasan keselamatan; hanya tradisi

A nurse teaches parents about firearm safety at home. Which statement shows a need for further teaching?

1. A“We keep all the ammunition locked away separately from the gun.”
2. B“We will ask other parents about guns before play dates.”
3. C“We keep the gun loaded in the nightstand, and the children know not to touch it.”
4. D“We store the gun unloaded in a locked safe in the bedroom.”

A blood sample drawn just after a patient ate a fatty meal is reported as "lipemic." What does this mean for the results?

1. AThe sample was contaminated by an IV fluid with dextrose
2. BThe results are more accurate than in a fasting sample
3. CThe sample shows the patient has diabetic ketoacidosis
4. DHigh fat in the sample may interfere with some test results

A patient in DKA is receiving IV fluids and insulin. The glucose has fallen to about 220 mg/dL (12,2 mmol/L), but the anion gap is still high. What change would the nurse expect?

1. AStop the IV fluids and start oral fluids only
2. BStop the insulin infusion because the glucose is near normal
3. CAdd dextrose to the IV fluids and continue the insulin
4. DGive an IV bolus of sodium bicarbonate at once

What should the nurse regularly check for a patient with a syringe driver?

1. AThe infusion site, the rate and volume remaining, and the patient's symptoms
2. BNothing, once the syringe driver is running
3. COnly that the battery is charged and the device is switched on
4. DOnly the patient's weight, measured once a week on the same scales

A potassium result of 6,9 mmol/L comes back on a well patient with a normal ECG, and the laboratory reports that the sample was haemolysed. What is the best action?

1. AGive IV insulin and glucose straight away
2. BRepeat the blood test promptly, as haemolysis can falsely raise potassium
3. CIgnore the result because the patient looks well and the ECG is normal
4. DStart a potassium supplement

When should an adult with cystic fibrosis take pancreatic enzyme capsules?

1. AOnce a day on waking, at least an hour before any food
2. BOnly at bedtime
3. CWith all meals and snacks that contain fat
4. DOnly when they have diarrhoea

Seorang pasien dengan penggantian katup mitral mekanik yang mengonsumsi warfarin memiliki INR 2,2. Apa yang harus dipertimbangkan perawat?

1. AINR sangat tinggi dan dosis harus ditahan
2. BINR seharusnya sekitar 1,0 untuk katup mekanik
3. CINR mungkin di bawah target pasien ini yang lebih tinggi, jadi periksa dan laporkan
4. DINR berada dalam rentang untuk setiap indikasi warfarin, sehingga tidak perlu tindakan

Why is good blood pressure control important in chronic kidney disease?

1. AIt slows the decline in kidney function
2. BIt raises the haemoglobin level in the blood
3. CIt lowers the blood glucose
4. DIt cures chronic kidney disease

A student has fever, a severe headache, a spreading non-blanching rash and a BP of 85/50 mmHg. A lumbar puncture is planned. What is the priority?

1. AGive paracetamol (acetaminophen) and recheck observations in an hour
2. BWait until after the lumbar puncture before giving antibiotics
3. CGive IV antibiotics at once and start sepsis treatment
4. DArrange a CT scan of the head before any treatment

Why is the time a surgical limb tourniquet is inflated carefully recorded?

1. AIt shows how long the anaesthetic gas was used
2. BThe surgeon is paid per minute of use
3. CLong inflation can cause nerve and muscle damage
4. DThe tourniquet slowly loses all its air after one minute

A nurse teaches a carer about overnight tube feeding at home. Which statement shows a need for further teaching?

1. A"I'll check the external length mark on the tube every day."
2. B"I'll flush the tube with water before and after his medicines."
3. C"I'll stop the feed and call if he coughs or struggles to breathe."
4. D"I'll let him lie flat so he sleeps better while the feed runs."