Prioritas & Delegasi ala NCLEX: paket kilat

Five days after starting heparin, a patient’s platelet count has fallen by more than half. What should the nurse suspect?

1. AHeparin-induced thrombocytopenia
2. BVitamin K deficiency
3. CAn expected effect that needs no action
4. DIron deficiency anemia

Setelah serah terima, pasien mana yang harus dikaji perawat lebih dulu?

1. APPOK dengan oksigen 2 L/menit: SpO₂ 90%, frekuensi napas 22/menit, pada kondisi dasarnya
2. B1 jam setelah kateterisasi jantung melalui femoralis: nyeri punggung baru, nadi 118/menit, TD 92/58 mmHg
3. CDiabetes tipe 2: glukosa 210 mg/dL (11,7 mmol/L) sebelum makan siang, tanpa gejala
4. DHari ke-2 setelah operasi kandung empedu: nyeri 6/10, analgesik berikutnya dijadwalkan 30 menit lagi

Before inserting a peripheral IV, the nurse cleans the skin with chlorhexidine-alcohol. What should the nurse do next?

1. ALet it dry fully and do not touch the site again
2. BBlow on the site so it dries faster
3. CWipe it off with a dry gauze straight away
4. DFeel for the vein again with an ungloved finger

A nurse sees a doctor about to insert a central line without a sterile gown, and a polite comment was ignored. Which TeamSTEPPS phrase helps to stop the procedure?

1. A“I am concerned, I am uncomfortable, this is a safety issue.”
2. B“I am sure you know what you are doing.”
3. C“I will mention this to the manager at the next staff meeting.”
4. D“Let’s talk about it after you have finished.”

Why must a blue-top (citrate) coagulation tube be filled to the correct level?

1. AThe blood-to-anticoagulant ratio must be right for accurate clotting times
2. BThe laboratory charges extra when a tube is not filled correctly
3. CAn overfull tube is needed to measure the potassium level
4. DUnderfilled tubes always give a falsely low hemoglobin and hematocrit

An 82-year-old woman without a catheter has a urine culture growing bacteria, but no fever, urinary symptoms or change in mental state. What is the best interpretation?

1. AA urinary tract infection that needs urgent IV antibiotics
2. BContamination, so the culture must be repeated every week
3. CAsymptomatic bacteriuria, usually not treated with antibiotics
4. DPyelonephritis, which needs admission and IV fluids today

A patient with dysphagia after a stroke has been cleared for a modified diet. How should they be positioned for meals?

1. ASitting fully upright, and staying upright for a time after eating
2. BLying on their side with the knees bent
3. CSemi-reclined at about 20 degrees, with the head supported on pillows
4. DLying flat on their back with the head turned to one side

Which patient should the nurse assess first?

1. AA patient with asthma who can only speak in single words
2. BA patient with COPD whose SpO₂ is 89% and within their target range
3. CA postoperative patient who rates their pain as 6/10
4. DA patient with diabetes whose glucose is 11 mmol/L (198 mg/dL) before lunch

A 70 kg patient has passed 20 mL of urine per hour for the last three hours. How should this be interpreted?

1. ABelow 0,5 mL/kg/h, suggesting poor kidney perfusion
2. BNormal, because any measurable urine output is reassuring
3. CHigh, suggesting fluid overload that needs a diuretic
4. DNormal, because the target is 0,1 mL/kg/h

Seorang pasien hipertensi diketahui memiliki TD 186/112 mmHg tanpa gejala dan tanpa tanda kerusakan organ. Respons mana yang paling tepat?

1. AMemeriksanya ulang, melaporkannya, dan mengantisipasi pengobatan oral selama jam hingga hari
2. BMemberikan bolus antihipertensi IV untuk mencapai 120/80 mmHg dalam 15 menit
3. CTidak mengambil tindakan, karena pasien merasa baik dan tanpa gejala
4. DMemanggil tim henti jantung dan bersiap untuk intubasi

A patient has just started levetiracetam. Which side effect should the nurse teach them to report?

1. AChanges in mood, such as irritability, low mood or anger
2. BA persistent dry cough at night
3. CSwelling and overgrowth of the gums around the teeth
4. DOrange discoloration of the urine

Two days after a spinal cord injury, a patient has a swollen abdomen, no bowel sounds and is vomiting. What is most likely, and what is the nursing action?

1. ANormal constipation, so give a large meal to stimulate the bowel
2. BAn allergic reaction to food, so give an antihistamine
3. CA full bladder, so encourage oral fluids
4. DParalytic ileus, so keep nil by mouth and prepare for an NG tube

Apa tanda paling awal hipertermia maligna selama anestesi?

1. ADenyut jantung melambat dan tekanan darah rendah
2. BKulit memerah dengan kadar CO₂ yang menurun
3. CPenurunan suhu tubuh yang stabil
4. DKenaikan CO₂ akhir ekspirasi yang tidak dapat dijelaskan

A category (stage) 4 pressure ulcer is now healing and shallower. How should it be documented according to standard guidance?

1. AAs a category 1 pressure ulcer now
2. BAs a category 2 pressure ulcer now
3. CAs a fully healed ulcer that can be removed from the record
4. DAs a healing category 4 pressure ulcer