Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A drowsy patient has an arterial blood gas with pH 7.30, PaCO₂ 58 mmHg (7.7 kPa) and HCO₃⁻ 25 mEq/L (mmol/L). Which problem is the priority?

1. APoor ventilation causing carbon dioxide to build up
2. BHyperventilation caused by anxiety
3. CLoss of bicarbonate from the bowel through severe diarrhea
4. DToo much bicarbonate from antacids

Di unit kardiak, pesakit manakah yang patut dilihat dahulu oleh jururawat?

1. APesakit fibrilasi atrium yang kadar denyutan jantungnya 88/min dan tidak teratur, seperti sebelumnya
2. BPesakit yang mengambil digoksin dengan nadi 48/min, loya dan kalium 3.0 mEq/L
3. CPesakit yang diminta berpuasa sebelum imbasan esok
4. DPesakit kegagalan jantung yang bertambah 0.3 kg sejak semalam

When should the transparent dressing over a peripheral IV site be changed?

1. AWhen it is damp, loose or visibly soiled
2. BEvery hour, so the site can be cleaned again
3. COnly when the patient asks for a new dressing
4. DOnly when the IV catheter is removed, whatever its state

During bedside handoff, the patient says, “I’m allergic to sulfa drugs,” but no allergy is recorded. What should the nurse do?

1. AWait until the patient is discharged to update the record
2. BTell the patient that sulfa drugs are always safe
3. CClarify the reaction, update the allergy record and tell the prescriber
4. DIgnore it, because the electronic record is more reliable than the patient’s memory

A patient's potassium is 7.0 mEq/L. Which ECG change would the nurse expect?

1. ADelta waves before the QRS
2. BProminent U waves
3. CTall, peaked T waves
4. DFlattened T waves

Dapatan manakah yang paling kuat mencadangkan bahawa kreatinin pesakit yang meningkat disebabkan oleh kecederaan buah pinggang akut dan bukan penyakit buah pinggang kronik yang lama?

1. APesakit mempunyai buah pinggang yang kecil pada imbasan ultrabunyi
2. BKreatinin normal tiga hari lalu dan telah berganda sejak itu
3. CPesakit mengalami anemia yang lama
4. DPesakit telah mempunyai kreatinin tinggi selama bertahun-tahun

A patient on insulin reports nightmares, night sweats and morning headaches. What should be suspected?

1. AA urinary tract infection
2. BRaised intracranial pressure
3. CNight-time hypoglycaemia
4. DHyperthyroidism

Set penemuan manakah yang paling baik membezakan kejutan kardiogenik daripada kejutan hipovolemik?

1. AKulit sejuk dan pucat
2. BTekanan vena jugular meningkat dan krepitasi paru-paru
3. CPengeluaran air kencing berkurang
4. DTakikardia, hipotensi dan nadi periferi yang lemah dan halus

A patient has episodes of severe headache, sweating and palpitations with very high blood pressure. Which rare cause should be considered?

1. AAortic stenosis
2. BAsthma
3. CStable angina
4. DPhaeochromocytoma

A nurse teaches a patient with heart failure who takes ramipril and spironolactone. Which statement shows a need for further teaching?

1. A"I will call if I gain weight quickly or get more breathless."
2. B"I will avoid ibuprofen for my joint pain."
3. C"I will weigh myself every morning after I go to the toilet."
4. D"I will use a salt substitute instead of ordinary salt."

Which picture fits anterior cord syndrome?

1. ANormal movement but complete loss of position sense
2. BArms much weaker than legs after a neck injury
3. CLoss of movement and pain sense, with position sense kept
4. DWeakness on one side and loss of pain sensation on the other side

A patient is being assessed for brain death (brainstem death). Which condition must be excluded before testing?

1. AEffects of sedative drugs or severe hypothermia
2. BA previous episode of migraine
3. CA history of high blood pressure
4. DA haemoglobin of 110 g/L (11 g/dL)

A patient received IV morphine 20 minutes ago and the surgical consent form has not been signed. What should the nurse do?

1. ASign the form on the patient's behalf as a witness
2. BAsk a relative to sign instead of the patient
3. CAsk the patient to sign quickly before they get sleepier
4. DTell the surgeon, as the patient may not be able to consent now

A patient is splashed in the eye with an alkaline cleaning product. What is the first action?

1. AAdd a few drops of vinegar to neutralise it
2. BAsk the patient to rub the eye to clear it
3. CCover the eye with a pad and wait for a doctor to examine it first
4. DIrrigate the eye at once with large volumes of water or saline