Prioritas & Delegasi ala NCLEX: paket kilat

Seorang pasien yang baru diberi tahu menderita kanker menangis, tetapi juga muntah beberapa kali dan tidak dapat menahan cairan. Apa yang ditangani perawat lebih dulu?

1. AEdukasi tentang kemoterapi
2. BDukungan emosional tentang diagnosis
3. CMenghubungi rohaniwan rumah sakit
4. DMuntah dan kehilangan cairan

Seorang pasien dengan trakeostomi baru batuk, napasnya berbunyi, dan SpO₂ turun menjadi 86%. Apa tindakan pertama?

1. AMemberikan bronkodilator nebulisasi
2. BMengganti pengikat trakeostomi
3. CMengisap (suction) trakeostomi
4. DMendokumentasikan SpO₂ dan memeriksa ulang dalam 30 menit

A visitor with a cold wants to see a patient who has severe neutropenia. What should the nurse advise?

1. AVisit as usual after washing the hands
2. BPostpone the visit until the visitor is well
3. CVisit but avoid touching the patient’s bed
4. DVisit only if the cold started more than a day ago

The laboratory reports that a blood sample labeled with one patient’s name has a blood group different from that patient’s previous result. What is the most likely problem and response?

1. AThe previous result was wrong, so it is deleted
2. BA normal change in the patient’s blood group over the years since the last test
3. CA laboratory machine fault, so no action is needed
4. DA wrong-patient sample, so the test is repeated and the event reported

Kapan pasien penyakit ginjal kronis harus mengonsumsi pengikat fosfat seperti kalsium asetat atau sevelamer?

1. AHanya ketika pasien merasa tidak enak badan
2. BHanya sekali seminggu
3. CMenjelang tidur dengan perut kosong
4. DBersama makan

Hasil aPTT sangat tinggi, tetapi perawat mengetahui bahwa sampel diambil dari lengan tempat infus heparin berjalan. Apa tindakan terbaik?

1. AMeminta sampel baru dari lengan sebelahnya sebelum dosis disesuaikan
2. BSegera memberikan protamin untuk menawarkan heparin
3. CMenerima hasil dan mengurangi kecepatan infus setengahnya
4. DMenghentikan infus heparin secara permanen dan memberi tahu penyedia layanan

A nurse gives a patient analgesia for post-operative pain. What should be done next?

1. AReassess the pain and any side effects once the drug has had time to work
2. BWait until the next shift before asking the patient about the pain
3. CGive a second analgesic straight away just in case
4. DAssume the pain has gone if the patient is quiet and has their eyes closed

A patient with a central venous catheter develops fever and rigors shortly after the line is flushed, with no other obvious source. What should be suspected?

1. AAn allergic reaction to the saline flush
2. BA catheter-related bloodstream infection
3. CNormal response to line use
4. DA pulmonary embolism

Seorang pasien mengalami fibrilasi atrium lebih dari 48 jam dan dijadwalkan untuk kardioversi elektif. Mengapa antikoagulasi diperlukan sebelumnya?

1. AAntikoagulan membuat kejutan listrik kurang menyakitkan
2. BAntikoagulan mengubah FA kembali ke irama sinus
3. CBekuan atrium dapat terlepas saat irama sinus kembali
4. DAntikoagulan mengurangi energi listrik yang dibutuhkan untuk kejutan

A patient with severe chronic kidney disease needs therapeutic anticoagulation for a DVT. Why might unfractionated heparin be chosen instead of a low-molecular-weight heparin?

1. AUnfractionated heparin has no bleeding risk at all
2. BUnfractionated heparin is taken by mouth
3. CLMWH is cleared by the kidneys and can accumulate
4. DLMWH cannot be given to anyone over 60

After transsphenoidal pituitary surgery, which advice should the patient follow?

1. ABlow the nose often to clear any clots
2. BLie completely flat for at least a week after surgery
3. CDrink through a straw to keep the nose clean
4. DAvoid blowing the nose, straining and bending forward

A patient with type 1 diabetes has a seizure on the ward. Their capillary glucose is 1,9 mmol/L (34 mg/dL). They cannot swallow. What is the most appropriate treatment?

1. AA rapid-acting insulin dose to stabilise the glucose
2. BGlucose gel squeezed into the mouth during the seizure
3. CAn antiepileptic drug only, because seizures need seizure treatment
4. DIV glucose or IM glucagon, then recheck the glucose

Which long-term effect must be monitored in patients receiving anthracyclines such as doxorubicin?

1. AExcess growth of body hair
2. BLoss of the sense of smell
3. CPermanent high blood glucose
4. DDamage to the heart muscle

Two days after surgery, a patient on regular ibuprofen has a low urine output and a rising creatinine, and intake has been poor. What should the nurse do?

1. AWithhold the next dose and report to the prescriber
2. BGive the next dose with extra food
3. CChange to a higher-strength NSAID tablet
4. DIncrease the dose to treat the pain better and encourage fluids