Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

During labor, the nurse sees the umbilical cord in the vagina after the membranes rupture. What is the first action?

1. AAsk the patient to walk around the room to bring the baby lower and speed up labor
2. BWait for the next contraction before acting
3. CPush the cord back into the uterus
4. DRelieve pressure on the cord by lifting the presenting part with a gloved hand

A patient with a head injury has a pupil on one side that is now large and does not react to light. What should the nurse do?

1. AReport it at once, as it may mean the brain is being compressed
2. BDocument it, because pupils often differ slightly after a head injury
3. CRecheck it at the next routine observation in four hours
4. DDim the room lights so the pupil can get smaller

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

1. AEncourage pregnant visitors to sit close to the patient to give emotional support
2. BPlace the patient on droplet precautions with a surgical mask
3. CLet the patient share a bathroom with other patients
4. DLimit time close to the patient and handle body fluids per radiation policy

An audit shows poor hand hygiene compliance on a ward. Which plan is most likely to improve it?

1. AA single poster about hand hygiene placed in the staff room
2. BRemoving all sinks so staff must use hand rub
3. CA combined approach with education, hand rub at every bedside, regular audits and feedback
4. DDisciplining staff who are seen not cleaning their hands, with no other change

A patient has weight loss, tremor and heat intolerance. Which thyroid test pattern fits Graves disease?

1. AHigh TSH with a low free T₄
2. BLow TSH with a high free T₄
3. CNormal TSH with a low free T₄
4. DHigh TSH with a normal free T₄

Seorang pesakit tanpa masalah buah pinggang dan ECG normal mempunyai kalium 6.2 mEq/L. Makmal mengulas bahawa sampel itu mengalami hemolisis. Apakah tafsiran yang terbaik?

1. APesakit mengalami kegagalan buah pinggang
2. BKeputusan mungkin tinggi secara palsu; nilai pesakit dan sediakan sampel ulangan
3. CKalium pasti normal dan tidak memerlukan tindakan susulan
4. DRawat serta-merta dengan insulin dan glukosa tanpa pemeriksaan lanjut

Pesakit kegagalan jantung mempunyai kahak merah jambu berbuih dan krepitasi di seluruh kedua-dua paru-paru. Apakah yang sedang berlaku?

1. APendarahan gastrousus atas
2. BPneumotoraks
3. CSerangan asma
4. DEdema pulmonari akut

A patient with lung cancer develops swelling of the face and arms, distended neck veins and breathlessness that is worse lying down. What should be suspected?

1. ASuperior vena cava obstruction
2. BHypothyroidism
3. CAn allergic reaction to food
4. DRight-sided heart failure from valve disease

Why must anti-embolism stockings be measured and fitted correctly?

1. ATight stockings work better, so the smallest size is always best
2. BLoose stockings make the patient's legs too warm at night
3. CCorrect fit is needed only to improve the appearance
4. DPoorly fitting stockings can cause pressure damage

Three days after an MI, a patient faints on the commode while straining hard to open the bowels. The heart rate was 42/min at the time. What is the most likely mechanism?

1. AAn allergic reaction to the commode
2. BA vagal response to straining
3. CA new pulmonary embolism
4. DLow blood glucose from fasting

Which measure best detects a decline in breathing in a patient with Guillain–Barré syndrome?

1. AOxygen saturation alone
2. BDaily chest X-rays
3. CRegular forced vital capacity measurements
4. DPeak flow before and after a bronchodilator

Seorang pesakit mempunyai fistula AV lengan kiri yang dibuat semalam dan memerlukan ujian darah rutin. Arahan manakah yang paling penting?

1. AMenggunakan lengan kanan; menyemak peredaran dan getaran tangan kiri
2. BMenggunakan tourniquet yang ketat pada lengan kiri untuk mencari vena yang baik
3. CMengambil darah daripada fistula, kerana ia mudah dicari dan besar
4. DMembalut lengan kiri dengan ketat dalam bebat untuk melindungi fistula

How should pancreatic enzyme replacement capsules usually be taken?

1. AWith every meal and snack
2. BOnly on days with abdominal pain
3. COne hour after meals, on an empty stomach
4. DOnce a day at bedtime

A patient finds daily wound dressing changes very painful. What is the most effective nursing approach?

1. AChange the dressing less often than the plan says
2. BGive analgesia timed so it works during the dressing change
3. CAvoid analgesia so the patient can report any problems during the change
4. DDo the dressing quickly and give analgesia afterwards