Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Before giving a medication to a child, which check is especially important?

1. AThat the dose is correct for the child’s weight
2. BThat the parent agrees with the time it is given
3. CThat the child likes the taste of the drug
4. DThat the medicine cup is the child’s favorite color

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 neutropenia after chemotherapy
3. CA patient with influenza on droplet precautions
4. DA patient with an MRSA wound infection

Which information must be documented when a patient is restrained?

1. AOnly whether the family agreed to the restraint
2. BOnly the time the restraint was put on and the time it was taken off
3. CThe reason, alternatives tried, type of restraint, times and regular assessments
4. DOnly the name of the nurse who applied it and the unit where it happened

Which patient with a suspected infection meets the qSOFA criteria that signal a higher risk of a poor outcome?

1. ARespiratory rate 24/min, new confusion, systolic BP 95 mmHg
2. BRespiratory rate 16/min, alert, systolic BP 105 mmHg, WBC 13,000/mm³
3. CRespiratory rate 20/min, alert, systolic BP 110 mmHg, heart rate 110/min
4. DRespiratory rate 18/min, alert, systolic BP 130 mmHg, temperature 38.5 °C

Why must a blue-top (citrate) coagulation tube be filled to the correct level?

1. AAn overfull tube is needed to measure the potassium level
2. BThe blood-to-anticoagulant ratio must be right for accurate clotting times
3. CUnderfilled tubes always give a falsely low hemoglobin and hematocrit
4. DThe laboratory charges extra when a tube is not filled correctly

A patient without diabetes in the ICU with sepsis has a glucose of 260 mg/dL (14.4 mmol/L) and an HbA1c of 5.2%. What is the best interpretation?

1. AType 1 diabetes from autoimmune damage
2. BStress hyperglycemia from acute illness
3. CLong-standing undiagnosed type 2 diabetes
4. DA meter error, because HbA1c is normal

Why must a patient with a new coronary stent not stop their antiplatelet medicines without specialist advice?

1. AThe stent will dissolve if the drugs are stopped before the course ends
2. BStopping causes immediate kidney failure
3. CStopping causes severe low blood pressure
4. DStopping early greatly increases the risk of a clot forming in the stent

A nurse notices that a wrong dose of a drug was prepared but was caught before it was given. What should be done?

1. ATell only the patient's family
2. BSay nothing, because no harm reached the patient
3. CReport it as a near miss through the incident reporting system
4. DDiscipline the nurse who prepared it on the spot in front of colleagues

Seorang pesakit yang baru memulakan antihipertensif berasa pening apabila bangun dari katil. Apakah nasihat yang betul?

1. AMengambil dos berganda pada pagi berikutnya sebagai ganti
2. BBerdiri dengan cepat supaya darah terus bergerak
3. CDuduk di tepi katil seketika sebelum berdiri
4. DBerhenti mengambil tablet tanpa memberitahu doktor atau jururawat

After a car crash, a patient is severely breathless with absent breath sounds on the right, a deviated trachea, distended neck veins and BP 76/40 mmHg. What is the immediate management?

1. ALying the patient flat with the legs raised
2. BA chest X-ray to confirm the diagnosis before any treatment
3. CUrgent needle or finger decompression of the right chest
4. DInsertion of a urinary catheter to monitor output

A stroke patient with dysphagia has been started on a modified diet. Which action best reduces the risk of aspiration?

1. AGive fluids through a straw so they flow more slowly
2. BLay the patient flat straight after meals so they can rest and digest
3. CFeed quickly so the patient does not tire during the meal
4. DSit the patient fully upright for meals and for a while afterwards

A patient on carbamazepine is admitted confused, with a sodium of 121 mmol/L. Which explanation is most likely?

1. AThe low sodium proves the patient has stopped taking the drug
2. BConfusion is a normal, expected effect of carbamazepine and is unrelated to sodium
3. CCarbamazepine can cause hyponatraemia through an SIADH-like effect
4. DCarbamazepine causes salt loss through severe diarrhoea

Which instruction is important during bowel preparation for colonoscopy?

1. ATake the preparation only if the bowels have not opened
2. BEat a high-fibre meal the evening before the test
3. CDrink plenty of clear fluids while taking the preparation
4. DAvoid all fluids for 24 hours before the test

A patient with facial burns from a house fire was talking normally on arrival. Two hours later, the voice is hoarse and there is stridor. What should the nurse do?

1. ALay the patient flat to help them sleep
2. BCall for urgent anaesthetic help, as the airway is swelling
3. CGive a warm drink to soothe the throat
4. DEncourage the patient to rest the voice and reassess tomorrow