Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A patient on a nasal cannula at 6 L/min still has a low SpO₂. What should the nurse do?

1. ARemove the oxygen to see if the SpO₂ changes
2. BTurn the nasal cannula up to 15 L/min
3. CReport it, because a different oxygen device is likely to be needed
4. DRecheck the SpO₂ at the next routine set of observations in four hours

A patient at 34 weeks of pregnancy has painless, bright red vaginal bleeding. Which action should the nurse avoid?

1. AA vaginal examination
2. BWeighing the pads to estimate blood loss
3. CMonitoring the fetal heart rate
4. DMeasuring the blood pressure and pulse

Mengapakah ubat cecair oral diberikan dengan picagari oral atau enteral dan bukannya picagari IV piawai?

1. ATiada sebab keselamatan; ia hanya tradisi
2. BPicagari oral tidak muat pada talian IV, mencegah kesilapan laluan yang salah
3. CPicagari oral menyukat dos intravena dengan lebih tepat
4. DPicagari IV tidak dapat menyukat isi padu kecil cecair oral dengan tepat

A nurse has just started a unit of red blood cells when a colleague asks for urgent help with another patient. What is the best action?

1. ASpeed up the transfusion so it finishes sooner
2. BStay with the transfusing patient for the first 15 minutes and ask another nurse to help
3. CLeave to help the other patient, and check the transfusion again in about an hour
4. DPause the transfusion until the nurse is free again

A patient with recurrent gout starts allopurinol. Which laboratory result shows that the treatment is achieving its goal?

1. AA rising white cell count
2. BA falling serum potassium
3. CA falling serum uric acid
4. DA rising serum calcium

A patient with SIADH is on fluid restriction. Which task can the RN delegate to unlicensed assistive personnel (UAP), such as a nursing or healthcare assistant?

1. ADeciding when to recheck the sodium level
2. BMeasuring and recording intake and output
3. CAssessing the patient for new confusion
4. DTeaching the reasons for fluid restriction

A nurse suspects that an older patient is being financially abused by a relative. What should the nurse do?

1. AKeep it secret because it is a family matter
2. BConfront the relative directly at the bedside about it
3. CWait until the patient has been discharged
4. DRaise the concern through the local safeguarding (adult protection) procedure

A patient with several days of vomiting and diarrhoea has low blood pressure, low urine output and a rising creatinine. Which description fits best?

1. AChronic kidney disease, treated with long-term dialysis three times a week
2. BPre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume
3. CPost-renal acute kidney injury from obstruction, treated with a catheter
4. DIntrinsic kidney injury from glomerulonephritis, treated with high-dose steroids

A patient arrives with suspected cardiac chest pain. How soon should a 12-lead ECG be recorded?

1. AOnly after the troponin result is available
2. BWithin about 10 minutes of arrival
3. CThe following morning
4. DWithin 2 hours of arrival

Saluran dada pesakit tercabut secara tidak sengaja. Apakah tindakan segera?

1. AMenolak saluran kembali ke dalam dada dan mengikatnya dengan pita
2. BMeminta pesakit batuk kuat untuk mengembangkan paru-paru
3. CMembiarkan lubang tidak bertutup supaya udara yang terperangkap boleh keluar
4. DMenutup tapak dengan pembalut oklusif steril dan mendapatkan bantuan

A patient with a suspected basal skull fracture needs a gastric tube. Which route is preferred?

1. AThrough a fine-bore nasal tube
2. BThrough the nose (nasogastric)
3. CThrough the mouth (orogastric)
4. DThrough the nose with a guidewire

An older man was found on the floor after lying there for many hours. His urine is dark brown, and his creatine kinase is very high. What is the main kidney risk and the key treatment?

1. AAKI from rhabdomyolysis, treated with generous IV fluids
2. BHypothermia, treated with a fluid restriction
3. CA urinary infection, treated with oral antibiotics only
4. DA kidney stone, treated with strong pain relief

Selama berapa lamakah langkah berjaga-jaga khas sering diambil dengan cecair badan selepas banyak ubat kemoterapi?

1. ASelama setahun penuh
2. BLazimnya kira-kira 48 jam
3. CHanya semasa infusi
4. DIa tidak pernah diperlukan

A patient with three fractured ribs is taking shallow breaths because of pain. Why is effective analgesia a priority?

1. APain relief is only needed for the patient's comfort
2. BRib pain always means the heart is damaged
3. CGood analgesia makes rib fractures heal fully within a few days
4. DShallow breathing can lead to atelectasis and pneumonia