Prioritas & Delegasi ala NCLEX: paket kilat

A young adult has just started an SSRI antidepressant for major depression. What should the nurse monitor most closely in the first weeks?

1. AWeight loss from too much appetite
2. BThoughts of suicide or self-harm
3. CRising blood glucose levels
4. DHair growth and skin color

An older adult with type 2 diabetes is confused and very dehydrated. The glucose is 900 mg/dL (50 mmol/L), and blood and urine show no significant ketones. What is the most likely problem?

1. AHyperosmolar hyperglycemic state
2. BStress-induced mild hyperglycemia
3. CHypoglycemia with rebound
4. DDiabetic ketoacidosis

Pemindai barcode memperingatkan bahwa obat tidak sesuai dengan catatan pasien. Apa yang harus dilakukan perawat?

1. ABerhenti dan mencari tahu penyebabnya sebelum memberikan obat
2. BMemberikan obat dan melaporkan peringatan nanti selama shift
3. CMemindai gelang pasien lain
4. DMengabaikan peringatan dan memberikan obat

A nurse finds a patient lying on the floor next to the bed. What should the nurse do first?

1. ATelephone the family to tell them about the fall
2. BLift the patient back into bed with a colleague
3. CAssess the patient for injury before moving them
4. DComplete an incident report while the details are fresh

Seorang pasien memiliki natrium 152 mEq/L. Temuan mana yang diharapkan perawat?

1. AKenaikan berat badan dengan pergelangan kaki bengkak
2. BHaus, selaput lendir kering, dan kegelisahan
3. CKedutan otot dengan tanda Trousseau positif
4. DBradikardia dengan gelombang T runcing

A patient on IV gentamicin has a trough level above the target, and the creatinine has risen since yesterday. The next dose is due. What is the best action?

1. AHold the dose and report the results to the prescriber
2. BGive the dose with extra oral fluids to protect the kidneys
3. CGive half of the dose and document the reason for it
4. DGive the dose now and recheck the levels next week

Why is an ankle–brachial pressure index (ABPI) measured before applying compression bandages to a leg ulcer?

1. ATo work out the patient's fluid needs
2. BTo exclude significant arterial disease, as compression could cut off blood flow
3. CTo measure how deep the ulcer is and how much exudate it produces
4. DTo check for a urinary tract infection that could delay ulcer healing

During a blood transfusion, an older patient with heart failure becomes breathless with a rising blood pressure, raised JVP and crackles in the lungs. What is the most likely cause?

1. AA febrile non-haemolytic reaction
2. BTransfusion-associated circulatory overload
3. CAnaphylaxis
4. DTransfusion-related acute lung injury with hypotension

Ciri mana yang paling menggambarkan ulkus arteri pada tungkai?

1. AUlkus nyeri, pucat, seperti terpotong (punched-out) di jari kaki dengan nadi kaki lemah
2. BUlkus dangkal dan lembap di atas pergelangan kaki bagian dalam dengan kulit cokelat
3. CUlkus tanpa nyeri di bawah bantalan telapak kaki dengan kalus tebal di sekitarnya
4. DUlkus yang berair di tulang kering dengan edema pitting pada tungkai

After a car crash, a patient is severely breathless with absent breath sounds on the right, a deviated trachea, distended neck veins and BP 76/40 mmHg. What is the immediate management?

1. ALying the patient flat with the legs raised
2. BA chest X-ray to confirm the diagnosis before any treatment
3. CInsertion of a urinary catheter to monitor output
4. DUrgent needle or finger decompression of the right chest

A patient with a suspected basal skull fracture needs a gastric tube. Which route is preferred?

1. AThrough the nose with a guidewire
2. BThrough the nose (nasogastric)
3. CThrough a fine-bore nasal tube
4. DThrough the mouth (orogastric)

Seorang pasien yang mengonsumsi litium mengalami poliuria dan haus, dan urine tidak memekat setelah desmopresin. Apa penyebab yang paling mungkin?

1. ADI sentral setelah cedera kepala
2. BSIADH akibat litium
3. CDiabetes tipe 1 yang baru muncul
4. DDI nefrogenik akibat litium

A dying patient can no longer drink. Which mouth care is most appropriate?

1. AFrequent, gentle moistening of the mouth and lips
2. BNo mouth care, to avoid disturbing the patient
3. CLemon and glycerine swabs every hour to stimulate saliva
4. DBrushing hard with a stiff toothbrush twice a day

A nurse teaches a patient after a colonoscopy with polyp removal. Which statement shows a need for further teaching?

1. A"I should report a fever or a swollen, painful abdomen."
2. B"Some wind and bloating today is expected."
3. C"Severe abdominal pain is normal for a week afterwards."
4. D"I'll report heavy bleeding from my bottom."