Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Lembaran formula, langkah kaedah utama untuk setiap topik dan 14 soalan latihan, dengan penyelesaian penuh di bahagian belakang.

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1Formula dan kaedah

Pemberian keutamaan & delegasi

Kaedah

  1. Tanya apa yang akan membahayakan pesakit paling cepat jika tiada apa-apa dilakukan.
  2. Gunakan ABC (C-A-B dalam henti jantung), kemudian Maslow: keperluan fisiologi sebelum keselamatan, keselamatan sebelum keperluan psikologi.
  3. Bandingkan pilihan: akut sebelum kronik, tidak stabil sebelum stabil, tidak dijangka sebelum dijangka, sistemik sebelum setempat, dan semak setiap penemuan dengan garis dasar pesakit.
  4. Nilai sebelum bertindak kecuali dalam kecemasan; kemudian pilih langkah yang menjadi tempat bergantung langkah-langkah lain.
  5. Untuk delegasi, semak lima hak: tugas, keadaan, orang, arahan dan penyeliaan. Penilaian, pengajaran dan penilaian semula kekal pada RN.

Kawalan jangkitan & keselamatan pesakit

Kaedah

  1. Mulakan dengan langkah berjaga-jaga standard untuk setiap pesakit: kebersihan tangan, PPE untuk pendedahan yang dijangka, benda tajam yang selamat.
  2. Tambah langkah berjaga-jaga mengikut laluan: sentuhan (gaun, sarung tangan), titisan (pelitup muka pembedahan), bawaan udara (N95, bilik tekanan negatif).
  3. Pastikan item steril kekal steril: jika ragu-ragu, ia tidak steril; gantikan, jangan sekali-kali dilap.
  4. Cegah bahaya dalam persekitaran: langkah pencegahan jatuh, sekatan hanya sebagai pilihan terakhir, RACE dan PASS untuk kebakaran.
  5. Semak hak pemberian ubat, dua pengenalpastian dan perlindungan tambahan untuk ubat berisiko tinggi; laporkan kesilapan dan hampir-hampir terlepas.

Nilai makmal & elektrolit

Kaedah

  1. Bandingkan nilai dengan julat rujukan makmal itu sendiri, kemudian dengan garis dasar dan arah aliran pesakit.
  2. Semak sampel: hemolisis, kelewatan, atau darah yang diambil berhampiran IV boleh memberikan keputusan palsu.
  3. Kaitkan nilai dengan tanda lazimnya dan dengan ubat serta keadaan yang menyebabkannya.
  4. Cari interaksi: kalium atau magnesium yang rendah meningkatkan ketoksikan digoksin; dehidrasi menaikkan litium.
  5. Bertindak untuk pesakit: nilai, tahan ubat jika paras tidak selamat, baca balik nilai kritikal dan maklumkan pemberi preskripsi.

Perubatan-pembedahan: kardiovaskular & respiratori

Kaedah

  1. Namakan masalah itu: kegagalan pam, arteri tersumbat, rentak, bekuan, penyempitan saluran udara, jangkitan atau masalah peranti.
  2. Semak tanda bahaya dahulu: hipoksia, hipotensi, sakit dada, kekeliruan baharu, anggota sejuk tanpa nadi.
  3. Padankan oksigen dengan pesakit: 94–98% untuk kebanyakan, 88–92% untuk mereka yang berisiko menahan CO₂.
  4. Kaitkan setiap ubat dengan ujian dan risikonya: warfarin dan INR, heparin dan aPTT serta platelet, diuretik dan kalium.
  5. Pilih tindakan pertama yang selamat, kemudian eskalasikan dan nilai semula.

Perubatan-pembedahan: neurologi, endokrin & renal

Kaedah

  1. Semak glukosa pada setiap pesakit dengan kekeliruan baharu, kelemahan atau sawan.
  2. Gunakan tahap kesedaran sebagai amaran paling awal masalah otak; pupil dan triad Cushing muncul lewat.
  3. Untuk kecemasan diabetes, bezakan DKA (keton, asidosis) daripada HHS (osmolaliti yang sangat tinggi, dehidrasi); berikan cecair dahulu.
  4. Untuk natrium dan air, tentukan sama ada ADH berlebihan (SIADH) atau tiada (DI), dan betulkan perubahan kronik secara perlahan.
  5. Untuk masalah buah pinggang, asingkan puncanya kepada pra-renal, intrinsik atau pasca-renal, dan pantau kalium dan cecair.

Perubatan-pembedahan: GI, perioperatif & onkologi

Kaedah

  1. Tanya apa yang mungkin tersembunyi: pendarahan dalaman, jangkitan tanpa demam, hipoventilasi di sebalik SpO₂ yang normal.
  2. Gunakan masa selepas pembedahan untuk mengecilkan komplikasi: pendarahan dalam beberapa jam, masalah dada dalam beberapa hari, masalah luka dan kebocoran kemudian.
  3. Untuk kesakitan, nilai, rawat dengan analgesia multimodal, nilai semula, dan pantau sedasi dengan setiap opioid.
  4. Untuk pesakit kanser, anggap sebarang penyakit semasa nadir sebagai sepsis neutropenik dan ketahui kecemasan onkologi.
  5. Untuk luka bakar, kira hanya kawasan ketebalan separa dan penuh, mulakan jam Parkland pada masa terbakar dan laraskan mengikut keluaran air kencing.

2Soalan latihan

1.Pemberian keutamaan & delegasiSederhana

Seorang dewasa yang stabil mengalami sakit perut dan tanda vital normal. Dia akan memerlukan ujian darah dan imbasan CT. ESI tahap manakah yang sesuai?

  1. ATahap 4
  2. BTahap 3
  3. CTahap 5
  4. DTahap 1
2.Pemberian keutamaan & delegasiSukar

A patient is bleeding internally after a fall. Which finding is usually an early sign of hypovolemic shock?

  1. AA slow heart rate with warm, dry, flushed skin and a normal blood pressure throughout
  2. BRestlessness and a rising heart rate while the blood pressure is still normal
  3. CA very low blood pressure with fixed, dilated pupils
  4. DLoss of consciousness with gasping breaths
3.Kawalan jangkitan & keselamatan pesakitSederhana

A patient has received oral radioactive iodine therapy. Which precaution is usually taken?

  1. ALimit time close to the patient and handle body fluids per radiation policy
  2. BLet the patient share a bathroom with other patients
  3. CEncourage pregnant visitors to sit close to the patient to give emotional support
  4. DPlace the patient on droplet precautions with a surgical mask
4.Kawalan jangkitan & keselamatan pesakitSukar

A nurse discovers that an insulin infusion was programmed using the wrong drug concentration in the pump library. What should the nurse do first?

  1. ALeave it running and check the glucose at the next routine time
  2. BDouble the rate to correct for the error
  3. CStop the infusion and check the patient’s blood glucose
  4. DReprogram the pump and finish the shift before reporting
5.Nilai makmal & elektrolitSederhana

A healthy patient's result is slightly outside the laboratory reference range, and all other results are normal. Which statement best explains why this can happen?

  1. AAny result outside the range always means disease is present
  2. BReference ranges are the same in every laboratory worldwide
  3. CRanges cover about 95% of healthy people, so some fall outside
  4. DReference ranges include every healthy person without exception
6.Nilai makmal & elektrolitSukar

Seorang pesakit kekurangan zat makanan mula makan semula dan, pada hari ke-3, mempunyai fosfat 1.2 mg/dL (0.39 mmol/L) dengan kelemahan otot dan sesak nafas. Apakah risiko utamanya?

  1. AOtot pernafasan yang lemah dan kegagalan jantung akibat fosfat rendah
  2. BPertambahan berat badan yang pantas, tetapi tiada bahaya serius
  3. CBatu karang akibat kalsium yang dibebaskan oleh tulang
  4. DHiperkalemia yang disebabkan oleh sel membebaskan kalium
7.Kejururawatan klinikalSederhana

A patient on haemodialysis has an arteriovenous fistula in the left arm. Which nursing care is correct?

  1. AKeep the arm raised and still at all times
  2. BApply a tight bandage over the fistula at night to protect it
  3. CUse the fistula arm for routine IV cannulas
  4. DAvoid blood pressure readings and blood samples on that arm
8.Kejururawatan klinikalSukar

A healthcare assistant reports four observations. Which one needs the nurse's immediate action?

  1. A"Mrs Jones would like a cup of tea and her glasses cleaned."
  2. B"Mr Chen's blood pressure is 128/80 as usual."
  3. C"Ms Ali has walked to the bathroom on her own."
  4. D"Mr Patel's breathing rate is 8 a minute and he's hard to wake."
9.Perubatan-pembedahan: kardiovaskular & respiratoriSederhana

A patient is on a short course of oral prednisolone for an asthma exacerbation. Which effect should the nurse monitor for?

  1. ARaised blood glucose
  2. BLow blood pressure
  3. CSlow heart rate
  4. DLow blood sodium
10.Perubatan-pembedahan: kardiovaskular & respiratoriSukar

A ventilated patient suddenly desaturates to 82%. The cause is not obvious and the ventilator alarms are sounding. What should the nurse do first?

  1. ASilence the alarm and wait for the result of the next routine blood gas
  2. BIncrease the sedation and watch the monitor for the next half hour
  3. CChange the ventilator settings to a higher rate
  4. DDisconnect and hand-ventilate with 100% oxygen while calling for help
11.Perubatan-pembedahan: neurologi, endokrin & renalSederhana

A patient's fistula starts to bleed at home after the needles were removed. What should they do first?

  1. ARaise the arm and let it bleed freely
  2. BApply a tight tourniquet above the fistula
  3. CPress firmly on the site with clean gauze
  4. DWait for the next dialysis session
12.Perubatan-pembedahan: neurologi, endokrin & renalSukar

An adult stares blankly for about a minute, smacks their lips and fumbles with their clothes. Afterwards they are confused for ten minutes and remember nothing. Which seizure type fits best?

  1. AAtonic (drop) seizure with a fall
  2. BMyoclonic seizure
  3. CAbsence seizure
  4. DFocal impaired awareness seizure
13.Perubatan-pembedahan: GI, perioperatif & onkologiSederhana

A day after a spinal anaesthetic, a patient has a headache that is worse when sitting up and better when lying flat. What is the most likely cause?

  1. AA side effect of the antibiotic
  2. BMigraine caused by hospital lighting
  3. CPost-dural puncture headache
  4. DRaised blood pressure from pain
14.Perubatan-pembedahan: GI, perioperatif & onkologiSukar

A patient admitted for an elective general anaesthetic mentions that they ate a slice of toast 3 hours ago. What should the nurse do?

  1. AAsk the patient to try to vomit to empty the stomach
  2. BGive a large drink to wash the food through
  3. CSay nothing, since toast is a light food
  4. DInform the anaesthetist, as surgery may be delayed

3Larutan

1.Pemberian keutamaan & delegasi

Jawapan: B · Tahap 3

Mengapa ini jawapannya

Ujian darah (satu sumber) ditambah imbasan CT (sumber kedua) menjadikan dua sumber, iaitu ESI tahap 3 apabila tanda vital boleh diterima.

Jawapan

B · Tahap 3
2.Pemberian keutamaan & delegasi

Jawapan: B · Restlessness and a rising heart rate while the blood pressure is still normal

Mengapa ini jawapannya

In early shock, the body keeps the blood pressure up by raising the heart rate and narrowing vessels, so restlessness and tachycardia appear first. A falling blood pressure is a later sign.

Jawapan

B · Restlessness and a rising heart rate while the blood pressure is still normal
3.Kawalan jangkitan & keselamatan pesakit

Jawapan: A · Limit time close to the patient and handle body fluids per radiation policy

Mengapa ini jawapannya

Radioactive iodine is excreted in urine, sweat and saliva, so the patient is usually in a private room with their own bathroom. Staff limit time near them, use distance and follow policy for body fluids and waste.

Jawapan

A · Limit time close to the patient and handle body fluids per radiation policy
4.Kawalan jangkitan & keselamatan pesakit

Jawapan: C · Stop the infusion and check the patient’s blood glucose

Mengapa ini jawapannya

A concentration error means the dose delivered was wrong. The nurse stops the infusion, assesses the patient including blood glucose, treats as needed, notifies the prescriber and reports the event.

Jawapan

C · Stop the infusion and check the patient’s blood glucose
5.Nilai makmal & elektrolit

Jawapan: C · Ranges cover about 95% of healthy people, so some fall outside

Mengapa ini jawapannya

A reference range is usually the central 95% of results from a healthy population, so about 1 in 20 healthy people will have a value just outside it. The result is interpreted with the clinical picture and previous values, and repeated if needed.Disemak dengan: How to Understand Your Lab Results · MedlinePlus (NIH) (2025)

Jawapan

C · Ranges cover about 95% of healthy people, so some fall outside
6.Nilai makmal & elektrolit

Jawapan: A · Otot pernafasan yang lemah dan kegagalan jantung akibat fosfat rendah

Mengapa ini jawapannya

Apabila pemakanan bermula semula, insulin memacu fosfat ke dalam sel, maka fosfat serum boleh jatuh mendadak (sindrom pemakanan semula). Hipofosfatemia teruk melemahkan diafragma dan jantung. Fosfat diganti, dan pemakanan ditingkatkan dengan perlahan.Disemak dengan: Refeeding Syndrome · StatPearls (NCBI Bookshelf)

Jawapan

A · Otot pernafasan yang lemah dan kegagalan jantung akibat fosfat rendah
7.Kejururawatan klinikal

Jawapan: D · Avoid blood pressure readings and blood samples on that arm

Mengapa ini jawapannya

The fistula arm is protected from pressure, cannulas and blood tests to prevent damage and clotting. Nurses check for a palpable thrill and audible bruit, which show it is working.

Jawapan

D · Avoid blood pressure readings and blood samples on that arm
8.Kejururawatan klinikal

Jawapan: D · "Mr Patel's breathing rate is 8 a minute and he's hard to wake."

Mengapa ini jawapannya

A low respiratory rate with reduced consciousness suggests respiratory depression, for example from opioids. It needs immediate assessment and escalation.

Jawapan

D · "Mr Patel's breathing rate is 8 a minute and he's hard to wake."
9.Perubatan-pembedahan: kardiovaskular & respiratori

Jawapan: A · Raised blood glucose

Mengapa ini jawapannya

Corticosteroids raise blood glucose, which matters especially in diabetes. Short courses can also cause mood changes, insomnia, indigestion and fluid retention. Long-term use adds osteoporosis, adrenal suppression and infection risk.

Jawapan

A · Raised blood glucose
10.Perubatan-pembedahan: kardiovaskular & respiratori

Jawapan: D · Disconnect and hand-ventilate with 100% oxygen while calling for help

Mengapa ini jawapannya

When a ventilated patient deteriorates suddenly, bag-valve ventilation with 100% oxygen takes the ventilator out of the picture. The nurse then checks for displacement, obstruction, pneumothorax and equipment failure (often remembered as DOPE) and calls for senior help.

Jawapan

D · Disconnect and hand-ventilate with 100% oxygen while calling for help
11.Perubatan-pembedahan: neurologi, endokrin & renal

Jawapan: C · Press firmly on the site with clean gauze

Mengapa ini jawapannya

Firm, direct pressure with clean gauze or a dressing is applied to the site. A tourniquet could clot the fistula. If bleeding does not stop, the patient calls emergency services, because fistula bleeding can be heavy.

Jawapan

C · Press firmly on the site with clean gauze
12.Perubatan-pembedahan: neurologi, endokrin & renal

Jawapan: D · Focal impaired awareness seizure

Mengapa ini jawapannya

Focal impaired awareness seizures often come from the temporal lobe. They last about a minute or two, with automatisms such as lip smacking and fumbling, and are followed by confusion. Absence seizures are shorter and have no postictal phase.

Jawapan

D · Focal impaired awareness seizure
13.Perubatan-pembedahan: GI, perioperatif & onkologi

Jawapan: C · Post-dural puncture headache

Mengapa ini jawapannya

CSF leaking through the dural puncture lowers pressure and causes a positional headache. Fluids, simple analgesia and caffeine may help, and the anaesthetist is informed; an epidural blood patch is sometimes needed.

Jawapan

C · Post-dural puncture headache
14.Perubatan-pembedahan: GI, perioperatif & onkologi

Jawapan: D · Inform the anaesthetist, as surgery may be delayed

Mengapa ini jawapannya

Solid food is usually stopped 6 hours before anaesthesia because of aspiration risk. The anaesthetist decides whether to delay or change the plan; the nurse reports accurately and does not hide the information.

Jawapan

D · Inform the anaesthetist, as surgery may be delayed

Ini ialah bahan latihan bebas. ExamProblems tidak berafiliasi dengan atau disokong oleh organisasi yang mengendalikan peperiksaan ini, dan nama peperiksaan hanya digunakan untuk menerangkan kandungannya. NCLEX®, NCLEX-RN® and NCLEX-PN® ialah tanda dagangan the National Council of State Boards of Nursing, Inc. (NCSBN), yang tidak bergabung dengan ExamProblems, tidak menyokongnya dan tidak menjamin ketepatannya.

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