Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Which infant with gastroenteritis should the nurse see first?

1. AAlert, crying with tears, had a wet diaper an hour ago
2. BTwo loose stools today, feeding well
3. CMild diaper rash, otherwise playful
4. DLethargic, sunken fontanel, no wet diaper for 8 hours

Four laboratory results come back at once. Which one should the nurse report first?

1. AGlucose 180 mg/dL after a meal in a patient with diabetes
2. BHemoglobin 6.5 g/dL (65 g/L) in a patient with a GI bleed
3. CPotassium 3.4 mEq/L in a patient on a diuretic
4. DCreatinine 1.3 mg/dL in an older adult, unchanged from last week

Where should the dispersive (grounding) pad for electrosurgery be placed?

1. AOn clean, dry skin over a well-perfused muscle, close to the surgical site
2. BOver an area with scar tissue or a tattoo, so that the pad does not slip
3. COver a bony prominence such as the hip bone
4. DOn skin that is wet with antiseptic prep

A patient on chemotherapy develops shingles over several areas on both sides of the body. Which precautions are needed?

1. ADroplet precautions until the pain settles
2. BAirborne and contact precautions until all lesions are crusted
3. CContact precautions only, with gloves for dressing changes
4. DStandard precautions only, with the lesions covered

A young adult with new diabetes has a very low C-peptide level. What does this suggest?

1. AThe kidneys are excreting all of the patient's insulin in urine
2. BThe patient has high insulin resistance, as in type 2 diabetes
3. CThe pancreas is making very little insulin, as in type 1 diabetes
4. DThe patient is injecting too much insulin and needs a lower dose

A patient's AST is about twice the ALT, both moderately raised, and the GGT is high. Which cause is most likely?

1. AAcute viral hepatitis A
2. BGallstone blocking the bile duct
3. CAcute myocardial infarction
4. DAlcohol-related liver disease

A very anxious patient breathes rapidly for a long period. Which change is expected?

1. AMetabolic alkalosis from vomiting
2. BMetabolic acidosis from a low bicarbonate
3. CRespiratory acidosis from a high PaCO₂
4. DRespiratory alkalosis from a low PaCO₂

Seorang pesakit kecederaan kepala menunjukkan tekanan darah meningkat, kadar jantung menurun dan pernafasan tidak teratur. Ini mencadangkan:

1. ASepsis
2. BTekanan intrakranial meningkat (triad Cushing)
3. CSerangan panik
4. DKejutan hipovolemik akibat pendarahan dalaman tersembunyi

A patient with chest pain has a first troponin result within the normal range one hour after the pain started. Why is a repeat test arranged?

1. ATroponin falls during an MI, so a lower value confirms it
2. BThe first sample is always contaminated
3. CTroponin may take a few hours to rise after muscle damage
4. DThe repeat test is only needed for patients over 80

A patient with a tracheostomy suddenly becomes distressed, and a suction catheter will not pass down the tube. What should the nurse do first?

1. AIncrease the oxygen and wait
2. BGive a nebulised bronchodilator
3. CInflate the cuff with more air
4. DRemove the inner cannula

A patient has acute low back pain with no red flags. Which advice is most appropriate?

1. AStay in bed for two weeks until the pain is gone
2. BAvoid all movement until an MRI scan has been done
3. CWear a rigid back brace all day and night for at least three months
4. DStay as active as possible and use simple pain relief

A patient with type 1 diabetes is vomiting at home. Their glucose is 12 mmol/L (216 mg/dL), and blood ketones are 3.5 mmol/L. What advice is correct?

1. ASeek urgent hospital assessment for possible DKA
2. BDrink less fluid to stop the vomiting
3. CWait until the glucose is above 20 mmol/L (360 mg/dL)
4. DStop insulin until the vomiting has settled

How does sucralfate help a peptic ulcer heal?

1. AIt kills H. pylori in the stomach lining
2. BIt forms a protective coating over the ulcer base
3. CIt speeds up emptying of the stomach
4. DIt blocks histamine receptors on parietal cells

On day 5 after hip surgery, a patient suddenly becomes breathless, with sharp chest pain on breathing in, a pulse of 120/min and SpO₂ 89%. What should the nurse suspect and do first?

1. ASimple atelectasis; encourage walking around the ward
2. BWound infection; take a wound swab and wait for results
3. CPulmonary embolism; sit up, give oxygen and call for urgent help
4. DAnxiety; give reassurance and repeat the observations in an hour's time