Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A patient receiving IV magnesium sulfate for pre-eclampsia has absent knee reflexes and a respiratory rate of 10/min. What does the nurse do first?

1. AStop the magnesium infusion and call for help
2. BTurn the patient onto her back and recheck later
3. CGive oral fluids to help clear the drug faster
4. DIncrease the infusion to prevent a seizure

A patient was knocked out briefly in a fall, then woke and talked normally. Two hours later the patient becomes drowsy and one pupil is larger. What is the most likely cause?

1. AA mild concussion that is settling
2. BAn epidural hematoma
3. CLow blood sugar from missing a meal
4. DNormal tiredness after a fall

Bilakah jururawat patut menggunakan pemadam api untuk memadamkan kebakaran?

1. ASentiasa, malah sebelum penggera dibunyikan, untuk menjimatkan masa
2. BHanya jika api kecil, penggera telah dibunyikan dan pintu keluar tidak terhalang
3. CSetiap kali ada asap, walaupun pintu keluar terhalang
4. DTidak pernah; hanya anggota bomba boleh menggunakan pemadam api

Seorang pesakit sedar yang berisiko tercekik sedang diberikan ubat oral. Amalan manakah yang paling selamat?

1. AMenghancurkan semua tablet tanpa menyemak sama ada ini dibenarkan
2. BMendudukkan pesakit tegak dan memberikan satu tablet pada satu masa
3. CMembaringkan pesakit mendatar menelentang untuk memudahkan menelan
4. DMemberikan semua tablet serentak untuk menjimatkan masa

A patient has a calcium of 11.8 mg/dL (2.95 mmol/L) from bone metastases. Which nursing measure is appropriate?

1. AEncourage fluids and mobility as tolerated
2. BEncourage bed rest and limit oral fluids
3. CGive calcium carbonate antacids for nausea
4. DOffer extra milk and cheese at each meal

A frail older adult in a nursing home has been drinking very little during a heat wave. She is confused, and her sodium is 158 mEq/L. Which treatment would the nurse expect?

1. ARapid infusion of 3% saline to raise the volume
2. BGradual replacement of free water over many hours
3. CA loop diuretic to remove the extra sodium quickly
4. DStrict fluid restriction to below 800 mL a day

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

1. AApply a tight bandage to the heels
2. BOffload the heels so they do not touch the mattress
3. CMassage the heels firmly several times a day to help circulation
4. DRest the heels on a rolled-up towel

In a patient with a head injury, which is usually the earliest sign of rising intracranial pressure?

1. AA change in level of consciousness
2. BA fixed, dilated pupil on both sides
3. CIrregular breathing pauses
4. DA slow pulse with high blood pressure

A patient has a heart rate of 36/min with hypotension and dizziness. Which drug is usually the first choice?

1. AOral bisoprolol
2. BIntravenous amiodarone
3. CIntravenous atropine
4. DIntravenous adenosine

A 28-year-old woman taking the combined pill comes in breathless and anxious. RR is 30/min, heart rate 118/min and SpO₂ 90% on air. A colleague says it is a panic attack. What should the nurse conclude?

1. AThe saturation is normal for an anxious person who is breathing fast
2. BLow oxygen saturation is not explained by anxiety; PE must be excluded
3. CShe should be sent home after a sedative
4. DBreathing into a paper bag is the best first treatment for her

Sawan telah berlangsung lima minit dan masih berterusan. Apakah rawatan ubat barisan pertama yang biasa?

1. AGlukosa 50% IV pada setiap pesakit, kemudian nilai semula
2. BAdrenalin IM ke dalam paha luar
3. CDos pemuat fenitoin IV sebelum apa-apa yang lain
4. DBenzodiazepin seperti lorazepam IV atau midazolam bukal

Seorang pesakit yang disyaki strok tiba dua jam selepas permulaan. Glukosa kapilari ialah 2.4 mmol/L (43 mg/dL). Apakah yang patut berlaku seterusnya?

1. AMengabaikan glukosa, kerana ia tidak relevan dengan penilaian strok
2. BMemberikan insulin IV untuk melindungi sel otak
3. CMerawat glukosa rendah dan menilai semula tanda neurologi
4. DMemberikan trombolisis serta-merta tanpa semakan selanjutnya

Apakah perbezaan klinikal utama antara sekatan usus kecil dan usus besar?

1. ATiada perbezaan klinikal; hanya imbasan CT yang dapat membezakannya
2. BUsus kecil: kembung ketara sahaja; usus besar: tiada sakit, tiada muntah dan tiada kembung langsung
3. CUsus kecil: tiada muntah langsung; usus besar: muntah awal yang banyak tanpa kembung
4. DUsus kecil: muntah awal, kurang kembung; usus besar: muntah lewat, kembung ketara

A sacral wound has heavy exudate, and the surrounding skin is white, soft and wrinkled. What should the nurse do?

1. ALeave the same dressing in place for a week so the wound is not disturbed
2. BProtect the skin edges and use a more absorbent dressing
3. CApply a tight plastic film directly over the wound
4. DUse a dressing that adds even more moisture