Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A drowsy patient has an arterial blood gas with pH 7.30, PaCO₂ 58 mmHg (7.7 kPa) and HCO₃⁻ 25 mEq/L (mmol/L). Which problem is the priority?

1. AHyperventilation caused by anxiety
2. BToo much bicarbonate from antacids
3. CPoor ventilation causing carbon dioxide to build up
4. DLoss of bicarbonate from the bowel through severe diarrhea

A patient admitted with suspected appendicitis says the pain suddenly got better, but now the abdomen is rigid and the heart rate is rising. What does this suggest?

1. AThe appendicitis is getting better without surgery
2. BThe appendix may have ruptured, causing peritonitis
3. CThe patient’s analgesic has finally started to work
4. DThe pain has moved to a different, harmless place

Salin steril tertumpah pada langsir steril yang terletak di atas meja tidak steril. Apakah maksudnya?

1. AMedan tercemar, kerana kelembapan boleh membawa organisma menembusi langsir
2. BMedan kekal steril, kerana salin itu steril
3. CMedan menjadi steril semula apabila ia kering
4. DHanya bahagian yang basah tercemar, jadi item boleh dialihkan ke bahagian yang kering

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

1. AComplete an incident report while the details are fresh
2. BAssess the patient for injury before moving them
3. CTelephone the family to tell them about the fall
4. DLift the patient back into bed with a colleague

Seorang pesakit dengan sindrom rembesan hormon antidiuretik yang tidak sesuai (SIADH) mempunyai natrium 128 mEq/L. Langkah ditetapkan manakah yang dijangka oleh jururawat?

1. AIsi padu besar glukosa 5% IV
2. BSekatan cecair
3. CDiet rendah natrium
4. DMenggalakkan pengambilan air tambahan

Mengapakah keputusan HbA1c boleh mengelirukan pada pesakit yang menerima transfusi darah yang banyak dua minggu lalu?

1. ATransfusi sentiasa menaikkan HbA1c kepada paras tinggi secara palsu
2. BBanyak sel darah merah ialah sel penderma, yang tidak terdedah kepada glukosa pesakit
3. CHbA1c mengukur gula pada sel darah putih, bukan sel darah merah
4. DHbA1c tepat dalam setiap situasi

When is a rapid-acting insulin such as insulin aspart usually given?

1. ATwo hours after finishing a meal
2. BOnly at bedtime
3. COnce a week
4. DJust before or with a meal

A nurse teaches a patient with diabetes about foot care. Which statement shows a need for further teaching?

1. A"I will walk barefoot at home to toughen my feet."
2. B"I will wear well-fitting shoes."
3. C"I will check my feet every day for cuts or blisters."
4. D"I will see the podiatrist about hard skin."

After thrombolysis for a myocardial infarction, which complication is the nurse most concerned to detect?

1. AConstipation from bed rest
2. BBleeding, including a sudden change in neurological status
3. CA skin rash appearing at the sites of the ECG electrodes
4. DA high blood glucose caused by the thrombolytic drug itself

A patient with heart failure wakes extremely breathless, coughing pink frothy sputum. BP is 168/96 mmHg and SpO₂ 86%. Help has been called. What is the best initial nursing action?

1. ASit the patient upright with the legs down and give oxygen
2. BEncourage the patient to walk to ease the breathing
3. CLie the patient flat with the legs raised on pillows
4. DGive a large IV fluid bolus to support the circulation

Which approach helps most when talking to a patient with expressive aphasia?

1. AFinish their sentences quickly to save them effort
2. BSpeak louder, because the patient cannot hear well
3. CAvoid talking to them until their speech has recovered
4. DAsk questions that can be answered with yes, no or a gesture

Seorang pesakit diabetes insipidus kranial memulakan desmopresin. Komplikasi manakah yang patut dipantau oleh jururawat?

1. AHiperglisemia
2. BHiponatremia
3. CHiperkalemia
4. DCirit-birit teruk

Why is IV albumin often given after a large-volume paracentesis?

1. ATo treat infection in the ascitic fluid
2. BTo replace the clotting factors and platelets lost in the drained fluid
3. CTo raise the blood glucose after the procedure
4. DTo prevent low blood pressure and kidney injury from fluid shifts

During burn resuscitation, a 70 kg adult's urine output has been 120 mL/h for 3 hours, and the face and limbs are very oedematous. What should the nurse do?

1. ADiscuss reducing the fluid rate with the team
2. BStop all IV fluids completely and remove the catheter
3. CIncrease the fluid rate to keep the output high
4. DGive a diuretic without discussing it