Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A patient with a spinal cord injury at T4 suddenly has a severe headache, flushing above the injury and a blood pressure of 200/110 mmHg. What does the nurse do first?

1. ASit the patient upright with the legs lowered
2. BApply extra blankets to keep the patient warm and calm
3. CGive a warm drink and recheck the blood pressure in an hour
4. DLay the patient flat with the legs raised

A dehydrated child is to receive IV fluids with added potassium. Which finding should the nurse confirm first?

1. AThat the child is hungry
2. BThat the child can walk without help
3. CThat the child’s temperature is normal
4. DThat the child is passing urine

An order reads “Give potassium chloride by IV push.” What should the nurse do?

1. AGive half by IV push and the rest later
2. BNot give it, and contact the prescriber, because it is never given by IV push
3. CDilute it in a small syringe and push it
4. DGive it slowly by IV push over two minutes while watching the cardiac monitor

A hospital will introduce new infusion pumps and wants to find out how the process could fail before any harm occurs. Which method fits best?

1. AFailure mode and effects analysis (FMEA)
2. BA morbidity and mortality meeting
3. CAn incident report for each new pump
4. DRoot cause analysis (RCA) of the new pumps

A patient has taken a proton pump inhibitor (such as omeprazole) for many years and now has muscle cramps and tremor. Which electrolyte is most likely to be low?

1. APhosphate
2. BSodium
3. CMagnesium
4. DChloride

A 68-year-old man has fatigue, a hemoglobin of 9.8 g/dL (98 g/L), an MCV of 72 fL and a low ferritin. He eats a normal diet. What is the most important next step?

1. AGive iron and do no further tests at all
2. BLook for a source of blood loss in the gut
3. CStart vitamin B₁₂ injections
4. DRepeat the blood count in one year

What is the best way to protect the heels of a bed-bound patient from pressure damage?

1. AOffload the heels so they do not touch the mattress
2. BApply a tight bandage to the heels
3. CRest the heels on a rolled-up towel
4. DMassage the heels firmly several times a day to help circulation

Pesakit yang mengambil antikoagulan jatuh dan terhantuk kepala tetapi kelihatan sihat. Apakah tindakan yang betul?

1. AGalakkan pesakit tidur tanpa pemerhatian
2. BBeri dos tambahan antikoagulan
3. CAturkan semakan perubatan dan kemungkinan imbasan CT, dengan pemerhatian neurologi
4. DTiada tindakan, kerana pesakit kelihatan sihat

Why is aspirin chewed rather than swallowed whole in a suspected acute coronary syndrome?

1. AWhole aspirin tablets cannot be absorbed at all from the gut
2. BChewing changes aspirin into an anticoagulant
3. CChewing speeds absorption, giving a faster antiplatelet effect
4. DChewing stops the aspirin from irritating the lining of the stomach

On day 2 after a surgical tracheostomy, the tube falls out. The patient is breathing but distressed. What should the nurse do first?

1. AForce the tube back through the stoma immediately with firm pressure
2. BLeave the patient alone while fetching a new tube
3. CCall for expert help and give oxygen to both the face and the stoma
4. DCover the stoma completely with a sealed dressing and wait for help

After a change in the levothyroxine dose, when is the TSH usually rechecked?

1. AAfter about 6–8 weeks
2. BAfter 3 days
3. CAfter 24 hours
4. DAfter about 2 years of treatment

Seorang wanita dengan epilepsi yang mengambil valproat berkata dia merancang kehamilan. Respons manakah yang paling sesuai?

1. AMenasihati supaya tidak menghentikannya secara tiba-tiba dan semakan pakar segera
2. BMencadangkan menggandakan dos untuk melindungi bayi daripada sawan
3. CMenyuruhnya berhenti mengambil valproat sepenuhnya mulai hari ini
4. DMenenangkannya bahawa valproat selamat sepanjang kehamilan

When is cold therapy most useful for pain?

1. AFor long-term muscle stiffness, applied continuously for several hours
2. BDirectly on skin with poor circulation
3. CSoon after an acute soft tissue injury, to reduce swelling
4. DOver numb areas where sensation is lost

On day 3 after surgery, a patient has a temperature of 38.6 °C, respiratory rate 24/min, pulse 118/min, BP 92/58 mmHg and new confusion. What should the nurse do?

1. AGive paracetamol and recheck in four hours
2. BEncourage oral fluids and wait for the doctor's round
3. CEscalate urgently and start the sepsis pathway
4. DRecord the observations and continue routine care