Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Monitor jantung menunjukkan garis rata (asistol) bagi seorang pesakit, tetapi pesakit itu duduk dan bercakap. Apakah yang dilakukan oleh jururawat dahulu?

1. AMemeriksa pesakit dan wayar elektrod
2. BMenyediakan defibrilator untuk memberi kejutan
3. CMemulakan penekanan dada serta-merta
4. DMemanggil pasukan henti jantung

A nurse sees a colleague put a vial of an opioid into their own pocket instead of returning it. What should the nurse do?

1. AAsk the colleague to share the vial with them
2. BReport it to the nurse manager according to policy
3. CTell the patients to watch the colleague carefully
4. DSay nothing, because it is not their business

A patient is on seizure precautions. Which equipment should be ready at the bedside?

1. ARestraints ready for all four limbs
2. BA tongue blade to put between the teeth
3. CAn ice pack to place on the forehead
4. DWorking suction and oxygen equipment

Which patient should the nurse assess first?

1. AA patient with an MRSA wound due for a routine dressing change
2. BA patient on chemotherapy with a new temperature of 38.4 °C (101.1 °F)
3. CA patient with tuberculosis who is asking to have visitors
4. DA patient who wants more alcohol hand rub in the room

When several samples are drawn at the same venipuncture, which tubes or bottles are filled first?

1. ACoagulation (citrate) tubes
2. BBlood culture bottles
3. CEDTA (complete blood count) tubes
4. DFluoride (glucose) tubes

Palung vankomisin seorang pesakit ialah 28 mcg/mL; sasaran yang ditetapkan pemreskripsi ialah 15–20 mcg/mL. Dos seterusnya perlu diberi sekarang. Apakah tindakan terbaik?

1. ABeri dos seperti dijadualkan dan semak semula paras palung dalam seminggu
2. BBeri dos dalam tempoh yang lebih singkat untuk mengurangkan pendedahan
3. CBeri dos berganda untuk menamatkan kursus dengan lebih cepat
4. DTahan dos, maklumkan pemreskripsi dan periksa fungsi buah pinggang

Why can a very low serum albumin contribute to oedema?

1. AIt increases the number of red cells
2. BIt makes the kidneys retain potassium
3. CIt raises the blood pressure in the capillaries and pushes fluid out
4. DIt lowers the oncotic pressure that holds fluid in the blood vessels

A patient is recognised by the team as being in the last days of life. Which approach is correct?

1. AAvoid talking with the family about what is happening
2. BContinue all routine blood tests and observations four-hourly
3. CReview and stop treatments that no longer help, and focus on comfort
4. DStop all medicines, including pain relief and anti-sickness drugs

What is the main difference between CPAP and bilevel NIV (often called BiPAP)?

1. ABilevel NIV gives oxygen only, without any positive airway pressure
2. BBilevel NIV adds a higher inspiratory pressure, helping remove CO₂
3. CCPAP is given only through a tracheostomy
4. DCPAP is mainly used to lower a raised PaCO₂ in COPD exacerbations

A patient on three blood pressure drugs still has high readings at every visit. What should the nurse check first?

1. AWhether the patient is taking the medicines as prescribed
2. BWhether a fourth drug can be added at today's appointment
3. CWhether the patient needs surgery on the renal arteries
4. DWhether the readings should be ignored

A bladder scan straight after voiding shows 450 mL of urine still in the bladder. What does this show?

1. AThe kidneys are making too little urine
2. BThe bladder is not emptying properly
3. CThe patient has drunk too little fluid
4. DThe patient is passing urine normally

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

Which drug class is used to reduce the risk of a first variceal bleed in cirrhosis?

1. ACalcium supplements
2. BProton pump inhibitors
3. CNon-selective beta-blockers
4. DThiazide diuretics

An older patient on regular opioids has small amounts of liquid stool leaking all day, but has not had a formed bowel movement for 6 days. What is the most likely cause?

1. AFaecal impaction with overflow
2. BNormal stool pattern on opioids
3. CA flare of ulcerative colitis
4. DAcute infective gastroenteritis