Prioritas & Delegasi ala NCLEX: paket kilat

Seorang perawat meminta asisten keperawatan menggunakan lift mekanis. Asisten mengatakan belum pernah dilatih menggunakannya. Hak pendelegasian mana yang dilanggar bila perawat berkeras?

1. AOrang yang benar
2. BPengawasan dan evaluasi yang benar
3. CArahan dan komunikasi yang benar
4. DTugas yang benar

A charge nurse notices that a nurse smells of alcohol and is slurring words at the start of the shift. What is the priority?

1. ARemove the nurse from patient care and report it according to policy
2. BAsk the nurse to drink coffee and then start work
3. CLet the nurse work, but only with stable patients
4. DWait until the end of the shift and then discuss the concern with the nurse privately

Which room lighting is safest at night for a patient at high risk of falls?

1. AComplete darkness so the patient sleeps more deeply
2. BA low night light that lights the path to the bathroom
3. COnly the light from the television screen
4. DBright overhead lights left on all night in the room

A patient takes medicines prescribed by several providers. Which advice best reduces the risk of medication errors at home?

1. AKeep one up-to-date list of all medicines and use one pharmacy where possible
2. BKeep each provider’s medicines in separate bags
3. COnly tell each provider about the drugs they prescribed
4. DStop taking any medicine that seems to repeat another one, without asking anyone

A patient with hyperkalemia received IV regular insulin with dextrose. Which result must the nurse monitor closely over the next hours?

1. ABlood glucose, because hypoglycemia can occur
2. BSerum calcium, because it falls sharply
3. CSerum sodium, because it rises quickly
4. DHemoglobin, because insulin causes red cell loss

Two weeks after a sore throat, a child develops dark (cola-colored) urine, puffy eyes and high blood pressure. Urinalysis shows red cell casts and protein. Which condition is most likely?

1. AKidney stone in the ureter
2. BPrerenal acute kidney injury
3. CPost-streptococcal glomerulonephritis
4. DLower urinary tract infection (cystitis)

In UK guidance, neutropenic sepsis is commonly defined by a temperature above 38 °C or signs of sepsis with a neutrophil count at or below:

1. A5 × 10⁹/L
2. B15 × 10⁹/L
3. C0,5 × 10⁹/L
4. D150 × 10⁹/L

Which action is most important in protecting a patient with severe neutropenia from infection?

1. AGiving routine intramuscular injections
2. BStrict hand hygiene by everyone who has contact with the patient
3. CKeeping fresh flowers and plants in the room to help the patient's mood
4. DTaking rectal temperatures regularly

After a prescribed IV fluid bolus for hypotension, what should the nurse do next?

1. AReassess heart rate, blood pressure, urine output and lung sounds
2. BStop all monitoring if the patient says they feel better
3. CStart a second fluid bolus straight away without checking anything
4. DWait until the next routine observations in four hours

Ten days after cardiac surgery, a patient has a fever, a red sternal wound with discharge and a clicking feeling in the chest when coughing. What should the nurse suspect?

1. APericarditis from the operation
2. BSternal wound infection with an unstable sternum
3. CNormal wound healing with some expected discharge
4. DCostochondritis caused by forceful coughing

A patient receives phenytoin through a nasogastric tube along with continuous enteral feed. Which issue should the nurse know about?

1. AThe feed can reduce phenytoin absorption, so the feed is often paused around the dose
2. BPhenytoin makes the feed curdle, so the two must never be used in one patient
3. CPhenytoin must be crushed and mixed into the feed bag
4. DThe feed increases phenytoin levels and causes toxicity within hours

A patient with polycystic kidney disease suddenly has the worst headache of their life and neck stiffness. What should the nurse suspect?

1. AA urinary infection that has spread
2. BA subarachnoid haemorrhage from a brain aneurysm
3. CPain spreading upwards from a kidney cyst
4. DA migraine linked to high blood pressure

Which lung problem is a known toxicity of bleomycin?

1. AAsthma from pollen
2. BPneumothorax from coughing
3. CLung cancer within weeks
4. DPulmonary fibrosis

A 60 kg adult with 25% TBSA burns arrives 2 hours after the injury, having had no IV fluids. Using the Parkland formula, what hourly rate is needed for the rest of the first 8 hours?

1. A500 mL/h
2. B250 mL/h
3. C375 mL/h
4. D1000 mL/h