Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A patient is receiving a blood transfusion. Which task can the nurse delegate to a nursing assistant?

1. AAssessing the patient for signs of a transfusion reaction
2. BStarting the transfusion once the blood arrives
3. CDeciding whether to stop the transfusion if the patient has chills
4. DMeasuring and reporting vital signs at the times set by the nurse

Two call lights go on at the same time. One patient has pain of 7/10 after surgery. The other is a confused patient at high risk of falls who is climbing out of bed alone. Who does the nurse go to first?

1. AWhichever patient’s room is closer to the station
2. BThe confused patient climbing out of bed
3. CThe patient whose call light went on first
4. DThe patient in pain after surgery

Setegang manakah sekatan pergelangan tangan patut dipasang?

1. ACukup longgar untuk tangan pesakit tergelincir keluar
2. BSeketat yang mungkin supaya pesakit tidak boleh menggerakkan lengan
3. CCukup ketat untuk memperlahankan nadi di pergelangan tangan
4. DCukup longgar untuk memuatkan dua jari di antara sekatan dan kulit

Victims of a chemical spill arrive at the emergency department with liquid on their skin and clothing. What is the priority before they enter the building?

1. ADecontaminate them outside, with staff wearing appropriate PPE
2. BTake a full history in the waiting room
3. CTake them straight into the resuscitation room so treatment is not delayed
4. DGive them hospital gowns and seat them in triage

A patient with iron-deficiency anemia started oral iron. Which result is usually the earliest sign that treatment is working?

1. AA fall in the mean cell volume (MCV)
2. BA fall in the white cell count
3. CA rise in the reticulocyte count
4. DA rise in the platelet count

A patient with schizophrenia drinks very large amounts of water each day. Sodium is 121 mEq/L, and the urine is very dilute (urine osmolality 70 mOsm/kg). Which explanation fits best?

1. AHyperosmolar hyperglycemic state
2. BCentral diabetes insipidus
3. CPrimary (psychogenic) polydipsia
4. DSyndrome of inappropriate ADH

Why is lactulose given to a patient with hepatic encephalopathy?

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

Which finding suggests hypocalcaemia?

1. ASpasm of the hand when a blood pressure cuff is inflated on the arm
2. BA slow, irregular pulse with nausea and yellow-tinged vision
3. CSevere thirst with a large urine output and constipation
4. DA flapping tremor of the outstretched hands

During an episode of chest pain, a patient's ECG shows new horizontal ST depression. What does this most likely indicate?

1. AA normal finding during pain
2. BMyocardial ischaemia
3. CHyperkalaemia
4. DPericarditis

During a cardiac arrest, the monitor shows an organised rhythm, but there is no pulse. What should the team do?

1. AGive adenosine to slow the rhythm down
2. BStop CPR, because an organised rhythm on the monitor means recovery
3. CDeliver an unsynchronised shock at once and then check the pulse
4. DContinue CPR and give adrenaline (epinephrine), as the rhythm is non-shockable

Pernyataan manakah tentang insulin basal bertindak panjang seperti glargin yang betul?

1. AIa diberikan hanya selepas makan besar untuk menampung karbohidrat
2. BIa dicampur dengan insulin bertindak pantas dalam picagari yang sama
3. CIa mempunyai kemuncak tindakan yang tajam kira-kira 30 minit selepas suntikan
4. DDalam diabetes jenis 1 ia diteruskan walaupun pesakit tidak makan

A patient with trigeminal neuralgia has lost weight and has poor oral hygiene. Which plan is most appropriate?

1. ATell the patient to stop brushing their teeth completely
2. BOffer soft, lukewarm food and advise chewing on the unaffected side
3. CAdvise very hot drinks to relax the facial nerves
4. DEncourage hard, crunchy foods to strengthen the jaw muscles

In the SBAR communication tool, what belongs under "A"?

1. AA list of the patient's allergies only
2. BThe patient's admission date only
3. CThe nurse's assessment of what the problem is
4. DThe address and phone number of the patient's next of kin

Two days after surgery, a patient on regular ibuprofen has a low urine output and a rising creatinine, and intake has been poor. What should the nurse do?

1. AWithhold the next dose and report to the prescriber
2. BGive the next dose with extra food
3. CIncrease the dose to treat the pain better and encourage fluids
4. DChange to a higher-strength NSAID tablet