Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A patient on a continuous IV heparin infusion has new black, tarry stools and an aPTT well above the target range. What should the nurse do first?

1. AGive a dose of vitamin K by mouth
2. BStop the heparin infusion and inform the provider
3. COffer an iron-rich meal to replace the lost blood
4. DCheck the pump rate and leave the infusion running

Semasa pemberian makanan tiub berterusan, seorang pesakit tiba-tiba mula batuk, sesak nafas dan SpO₂ menurun. Apakah tindakan pertama jururawat?

1. ABaringkan pesakit rata supaya dia boleh berehat
2. BTingkatkan kadar pemberian makanan supaya ia selesai lebih awal
3. CHentikan pemberian makanan, dudukkan pesakit tegak dan nilai pernafasan
4. DBilas tiub dengan 50 mL air, kemudian teruskan pemberian makanan seperti sebelumnya

Sisa pembalut manakah yang patut dilupuskan sebagai sisa klinikal (bahaya biologi)?

1. ABungkus kertas luar bagi bungkusan pembalut steril
2. BPembalut yang tidak digunakan dan masih bertutup tetapi telah melepasi tarikh luput
3. CPembalut yang direndam dengan cecair daripada luka yang dijangkiti
4. DTuala kertas bersih yang digunakan untuk mengeringkan tangan

In START triage, a casualty cannot walk and is breathing 36 times a minute. Which category applies?

1. AYellow (delayed)
2. BGreen (minor)
3. CBlack (expectant or dead)
4. DRed (immediate)

Makmal menelefon wad dengan keputusan kritikal kalium 6.9 mEq/L. Apakah yang patut dilakukan oleh jururawat?

1. ABaca semula nilai itu, nilai pesakit dan maklumkan pembekal
2. BRekodkan nilai itu dan serahkan kepada syif seterusnya
3. CTunggu laporan bertulis tiba sebelum mengambil sebarang tindakan
4. DMinta makmal mengulang ujian sebelum memberitahu sesiapa

A patient's potassium is 7.2 mEq/L, and the monitor shows wide QRS complexes. Several treatments are prescribed. Which should be given first?

1. AIV furosemide (a loop diuretic)
2. BAn oral potassium binder dose
3. CIV calcium gluconate (or chloride)
4. DUrgent hemodialysis session

A dying patient can no longer drink and has a dry mouth. What is the most appropriate nursing care?

1. AInserting a nasogastric tube for fluids
2. BFrequent mouth care that keeps the lips and mouth moist
3. CLeaving the mouth alone to avoid disturbing them
4. DStarting a fast intravenous infusion to correct the dryness

A patient has a single hot, swollen, very painful knee and a fever. Why is urgent joint aspiration important?

1. ATo check for rheumatoid arthritis antibodies in the joint fluid
2. BTo measure the patient's cholesterol
3. CTo rule out septic arthritis, which can rapidly destroy the joint
4. DTo prevent osteoporosis

How is orthostatic (postural) hypotension usually assessed?

1. ABP in both arms at the same moment while sitting
2. BBP only standing, after a brisk walk along the corridor
3. CBP once sitting, then once lying down straight after a large meal
4. DBP lying after rest, then again after 1 and 3 minutes standing

The monitor shows a regular broad-complex tachycardia at 180/min. The patient is alert with BP 126/78 mmHg and no chest pain. What is the most appropriate plan?

1. AReassure the patient, as this is a normal rhythm
2. BStart chest compressions straight away and give a dose of IV adrenaline
3. CDeliver an unsynchronised shock immediately, before any other assessment
4. DRecord a 12-lead ECG, call senior help and anticipate an antiarrhythmic

Which picture fits Brown-Séquard syndrome?

1. AWeakness on the same side and loss of pain on the opposite side
2. BParalysis of both legs, with normal sensation everywhere in the body
3. CWeakness of both arms with normal strength in the legs
4. DLoss of all feeling but normal movement on both sides

A patient with an insulin pump is admitted with nausea, a glucose of 19 mmol/L (342 mg/dL) and blood ketones of 3.1 mmol/L. What is the priority?

1. ASuspect failed insulin delivery and give insulin by another route
2. BGive an antiemetic only, because nausea is causing the high glucose
3. CDisconnect the pump and give no insulin until the ketones clear
4. DIncrease the pump rate and recheck the ketones in 12 hours

Which is a common side effect of opioids, especially when given by epidural or spinal route?

1. ARinging in the ears
2. BHair growth
3. CItching
4. DIncreased hunger

A worker has a hydrofluoric acid burn on the hand and severe pain. After irrigation with water, which specific treatment is commonly applied?

1. ASodium bicarbonate paste
2. BIce cubes wrapped in a cloth
3. CCalcium gluconate gel
4. DSilver sulfadiazine cream