Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Seorang jururawat menerima empat loceng panggilan pada masa yang sama. Pesakit manakah yang didatangi dahulu oleh jururawat?

1. APesakit yang bertanya pukul berapa doktor akan datang
2. BPesakit yang pam IVnya berbunyi kerana beg cecair penyelenggaraan telah habis
3. CPesakit yang meminta ubat penahan sakit untuk kesakitan 4/10
4. DPesakit yang berkata, "Saya tidak dapat bernafas."

During birth, the baby’s head delivers but the shoulders do not follow. What should the nurse do first?

1. APull hard on the baby’s head and neck to free the trapped shoulders quickly
2. BHelp with the McRoberts position and give suprapubic pressure as directed
3. CAsk the mother to stop pushing and wait an hour
4. DPush firmly on the top of the uterus (fundal pressure)

Seorang jururawat mengalami kecederaan tertusuk jarum daripada pesakit yang diketahui menghidap HIV. Mengapakah penting untuk melaporkannya dengan segera?

1. APelaporan hanya diperlukan bagi kecederaan daripada jarum IV
2. BPelaporan hanya diperlukan jika luka berdarah atau dalam
3. CProfilaksis pasca-pendedahan paling berkesan jika dimulakan dalam masa beberapa jam
4. DPelaporan boleh dibuat pada bila-bila masa dalam sebulan tanpa mengubah risiko

A patient is on contact precautions. Which task is appropriate for the nurse to delegate to assistive personnel?

1. AAssessing the wound for new signs of infection during the bath
2. BTeaching the family how to follow the precautions
3. CDeciding when the precautions can be stopped
4. DHelping the patient bathe while wearing a gown and gloves

A patient has started parenteral nutrition (PN) through a central line. Which test is monitored most frequently in the first days?

1. ASerum lipase
2. BHemoglobin A1c
3. CThyroid hormones
4. DBlood glucose

A patient using an insulin pump has a glucose of 300 mg/dL (16.7 mmol/L) that has not fallen 2 hours after a correction bolus through the pump. Blood ketones are 1.8 mmol/L. What is the most likely problem and action?

1. AInsulin overdose from the pump; suspend the pump and stop all insulin for a day
2. BNormal pump function; wait for the next mealtime bolus to lower the glucose
3. CInsulin delivery failure; inject a correction dose by pen and change the set
4. DRebound after a hypo; give fast-acting carbohydrate and recheck in 15 minutes

Why is lactulose given to a patient with hepatic encephalopathy?

1. ATo increase the liver's production of albumin
2. BTo stop bleeding from varices
3. CTo reduce the absorption of ammonia from the gut
4. DTo lower the blood glucose

During CPR for asystole, when should adrenaline (epinephrine) be given according to standard adult guidelines?

1. AOnly after three shocks have been delivered by the defibrillator
2. BAs soon as IV or IO access is obtained, then every 3–5 minutes
3. CNever, because asystole is not treated with drugs
4. DOnly once the patient has a pulse again

Seorang pesakit penyakit arteri periferi mengalami sakit kaki pada waktu malam. Posisi manakah yang boleh melegakannya?

1. AMenjuntaikan kaki ke bawah di tepi katil
2. BMembalut kaki dengan bebat mampatan
3. CMenaikkan kaki di atas bantal melebihi paras jantung
4. DMeletakkan botol air panas terus pada kaki

A patient with severe sepsis becomes increasingly breathless over 24 hours. SpO₂ stays low despite high-flow oxygen, and the chest X-ray shows bilateral infiltrates. The heart function is normal. Which condition is most likely?

1. ASpontaneous pneumothorax
2. BAn acute asthma attack
3. CAcute left ventricular failure after an MI
4. DAcute respiratory distress syndrome

A patient takes levodopa for Parkinson's disease. Which teaching point is correct?

1. AThe drug cures the disease if taken for a full year
2. BLarge high-protein meals can reduce how well the drug works
3. CThe tablets work best taken with a large steak dinner
4. DStop the drug for a day each week to avoid tolerance

An 89-year-old with stage 5 CKD and severe heart failure, who has capacity, decides not to start dialysis. What is the nurse's best response?

1. ATell the patient they must start dialysis by law
2. BStop all care, because nothing more can be done
3. CAsk the family to change the patient's mind
4. DRespect the decision and support symptom-focused care

Which nerve is at risk if the arm is poorly padded at the elbow during surgery?

1. AFemoral nerve
2. BSciatic nerve
3. CFacial nerve
4. DUlnar nerve

Pada hari ke-2 selepas pembedahan abdomen atas, seorang pesakit mempunyai suhu 37.8 °C, SpO₂ 93% pada udara bilik dan bunyi nafas berkurang di kedua-dua dasar. Mereka tidak menggunakan spirometer insentif kerana kesakitan. Apakah pelan kejururawatan yang paling sesuai?

1. AMemberikan oksigen pada 15 L/min dan membiarkan pesakit berehat dengan tenang
2. BMemastikan pesakit di katil dan menyekat pergerakan sehingga demam reda
3. CMenghentikan semua analgesia supaya pesakit boleh batuk dengan lebih kuat
4. DKawalan kesakitan yang lebih baik, duduk tegak, pernafasan dalam, mobilisasi dan melapor