Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Two hours after birth, the nurse finds the uterus firm but above the umbilicus and pushed to the right. What should the nurse do first?

1. AAsk the patient to lie still for another hour
2. BMassage the uterus firmly for ten minutes
3. CGive a dose of oxytocin straight away
4. DHelp the patient empty her bladder

Four stable patients need routine morning care. To reduce the spread of infection, which patient should the nurse visit first?

1. AA patient with C. difficile diarrhea
2. BA patient with influenza on droplet precautions
3. CA patient with neutropenia after chemotherapy
4. DA patient with an MRSA wound infection

A newly hired nurse had BCG vaccine as a child. Which TB screening test is usually preferred?

1. AAn interferon-gamma release assay (IGRA) blood test
2. BA chest x-ray every month for the first year
3. CNo screening, because BCG prevents all TB
4. DA tuberculin skin test, which is read 24 hours after it is placed

A nurse teaches new parents about safe infant sleep. Which statement shows a need for further teaching?

1. A“We will keep the crib in our room, next to our bed, for the first months.”
2. B“We will lay the baby on the back for every sleep, including naps.”
3. C“We will put a soft bumper pad and a blanket in the crib so the baby is cozy.”
4. D“We will not smoke near the baby.”

A patient with type 1 diabetes has the flu, is eating little and has a glucose of 290 mg/dL (16.1 mmol/L). Which advice is correct?

1. AStop all insulin until you are eating normally again
2. BKeep taking insulin and check blood or urine ketones
3. CDrink only water and avoid all carbohydrate foods
4. DWait 3 days before checking the glucose again

Which patient should the nurse assess first?

1. AHeart failure with a BNP lower than the result on admission
2. BHypertension with a potassium of 3.6 mEq/L on a thiazide
3. CStable angina with a total cholesterol of 245 mg/dL (6.3 mmol/L)
4. DChest pain with troponin rising from the first to the second sample

A confused patient keeps trying to climb out of bed. Why are bed rails not automatically the answer?

1. APatients can be seriously injured climbing over or becoming trapped in rails
2. BBed rails are illegal in all hospitals and must never be used at all
3. CBed rails stop staff from taking observations
4. DBed rails always make patients more confused, but only during the day

A patient with poorly controlled hyperthyroidism develops a high fever, very fast heart rate, agitation and vomiting during an infection. What is likely?

1. AMyxoedema coma
2. BAddisonian crisis
3. CThyroid storm
4. DHypoglycaemia

A peripheral cannula site is red, warm, tender and swollen along the vein. What should the nurse do?

1. AFlush the cannula hard to clear it
2. BCover the site and keep using it until it blocks
3. CLeave it in place, as this is normal after 24 hours
4. DRemove the cannula, document and monitor the site

A 74-year-old man with a known abdominal aortic aneurysm suddenly has severe back and abdominal pain. His heart rate is 128/min and BP 82/50 mmHg. What is the priority?

1. ACall for emergency help and prepare for urgent vascular surgery
2. BArrange a routine outpatient ultrasound scan of the aneurysm
3. CEncourage him to walk to ease the back pain
4. DGive oral analgesia and reassess the pain in an hour

A routine blood test shows a potassium of 6.4 mmol/L. The lab reports that the sample was haemolysed. The patient feels well. What should the nurse do?

1. AIgnore it, because haemolysis always gives a normal result
2. BInform the doctor and arrange an urgent repeat sample
3. CStart dialysis as soon as possible
4. DGive oral potassium supplements straight away

A patient has frothy urine and marked leg swelling. Serum albumin is 18 g/L (1.8 g/dL), and BP is normal. The urine shows heavy protein but little blood. What is most likely?

1. AAcute pyelonephritis
2. BNephritic syndrome
3. CA urethral stricture
4. DNephrotic syndrome

Which statement correctly describes physical dependence on opioids?

1. AThe patient is allergic to opioids
2. BThe drug no longer has any side effects
3. CWithdrawal occurs if the drug is stopped suddenly
4. DThe patient always craves the drug and misuses it despite harm

A nurse teaches a patient after a laparoscopic fundoplication for reflux. Which statement shows a need for further teaching?

1. A"Fizzy drinks will help me bring up wind after meals."
2. B"Some difficulty swallowing can happen in the early weeks."
3. C"I'll eat soft, moist food at first and chew it well."
4. D"I should eat smaller meals for a while after the operation."