Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Which patient is most suitable for the nurse to assign to a nurse who has just finished orientation?

1. AA patient with a new tracheostomy who needs frequent suctioning
2. BA patient with sepsis whose blood pressure is falling
3. CA patient with stable cellulitis on scheduled IV antibiotics
4. DA patient on a continuous heparin infusion with rising aPTT values

A day after a femur fracture, a young patient becomes confused and breathless, with small red spots on the chest. What should the nurse suspect?

1. AAn allergic reaction to the cast
2. BAlcohol withdrawal
3. CNormal pain after a fracture
4. DFat embolism syndrome

Seorang pesakit yang menggunakan diuretik berisiko tinggi jatuh dan kerap bangun pada waktu malam. Langkah manakah yang paling membantu?

1. AMemastikan bilik gelap sepenuhnya pada waktu malam untuk membantu pesakit tidur
2. BPenjadualan ke tandas, dengan lampu panggilan dan alat bantu berjalan dalam capaian
3. CMemberitahu pesakit supaya tidak minum apa-apa selepas makan tengah hari
4. DMemberikan diuretik pada waktu tidur supaya ia berfungsi sepanjang malam

A nurse notices that the pharmacy has sent the wrong dose and corrects it before giving it. Should the event be reported?

1. ANo, because the patient was not harmed
2. BOnly if the same error happens three times
3. CNo, because reporting near misses only blames the pharmacy staff for nothing
4. DYes, near misses are reported so system weaknesses can be fixed

Seorang pesakit sirosis mempunyai albumin 2.2 g/dL (22 g/L). Dapatan manakah yang paling berkaitan?

1. AHiperkalemia
2. BTekanan darah tinggi
3. CPeningkatan keluaran air kencing
4. DEdema dan asites

A patient has fatigue, weight gain and constipation. Results: TSH 24 mIU/L, free T₄ low, total cholesterol 285 mg/dL (7.4 mmol/L), sodium 131 mEq/L. What is the best interpretation?

1. AHyperthyroidism, with suppressed thyroid hormone production
2. BSecondary hypothyroidism from failure of the pituitary gland
3. CFamilial hypercholesterolemia, unrelated to the thyroid results
4. DPrimary hypothyroidism, which can raise lipids and lower sodium

Semasa infusi IV, kawasan di sekeliling kanula menjadi bengkak, sejuk dan pucat, dan infusi menjadi perlahan. Apakah yang mungkin berlaku?

1. AFlebitis akibat jangkitan bakteria pada dinding vena
2. BLebihan cecair dalam peredaran
3. CEmbolisme udara
4. DInfiltrasi cecair ke dalam tisu sekeliling

A hypotensive postoperative patient is given a fluid bolus. Which findings suggest a good response?

1. AThe heart rate rises further and the patient becomes more confused
2. BThe respiratory rate rises and new lung crackles appear
3. CThe capillary refill time becomes longer
4. DThe heart rate falls, blood pressure rises and urine output improves

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

1. AAsthma
2. BPhaeochromocytoma
3. CStable angina
4. DAortic stenosis

A patient with severe COPD has increasing ankle oedema and a raised JVP, but no crackles and a normal left ventricle on echocardiography. Which condition is most likely?

1. ALeft ventricular failure
2. BAortic stenosis
3. CCor pulmonale
4. DDeep vein thrombosis

Set keputusan manakah yang paling menyokong DKA dan bukan HHS?

1. AGlukosa melebihi 30 mmol/L dengan pH normal
2. BKeton normal dan bikarbonat normal
3. CKeton tinggi, pH di bawah 7.3 dan bikarbonat rendah
4. DOsmolaliti sangat tinggi dengan keton jejak sahaja dalam darah

The nurse has four endocrine patients. Which one needs to be seen first?

1. AA patient with hypothyroidism who has been constipated for three days
2. BA patient with hyperthyroidism who is confused, with a temperature of 39.5 °C (103.1 °F)
3. CA patient with Graves' disease asking about radioactive iodine
4. DA patient after thyroidectomy with mild pain on swallowing

Pembalut manakah yang pada amnya sesuai untuk luka kering yang berslaf yang memerlukan kelembapan?

1. AAlginat
2. BKasa kering
3. CHidrogel
4. DSpan (foam)

A patient on warfarin has a major upper GI bleed with an INR of 5. Which treatment should the nurse anticipate to reverse the warfarin?

1. AOral aspirin to balance the clotting system quickly
2. BProthrombin complex concentrate with IV vitamin K
3. CMore warfarin to stabilise the INR
4. DProtamine sulfate on its own