Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A nurse gives IV morphine for severe pain. When should the nurse reassess the pain and sedation?

1. AWithin about 15–30 minutes
2. BOnly when the patient asks for more
3. CAt the next routine round in four hours
4. DAt the end of the shift

A patient in labor is receiving oxytocin, and the fetal monitor shows repeated late decelerations. What should the nurse do first?

1. AEncourage the patient to start pushing
2. BPlace the patient flat on her back
3. CIncrease the oxytocin rate
4. DStop the oxytocin infusion

Seorang pesakit menghidap kayap (herpes zoster) pada satu kawasan dada, mempunyai sistem imun yang normal dan lesi boleh ditutup sepenuhnya. Langkah berjaga-jaga yang manakah lazimnya diperlukan?

1. ALangkah berjaga-jaga standard, dengan lesi ditutup
2. BLangkah berjaga-jaga udara dalam bilik bertekanan negatif
3. CLangkah berjaga-jaga titisan sahaja
4. DPersekitaran perlindungan dengan tekanan positif

Seorang jururawat tiba di tempat kebakaran di koridor dan api sedang merebak. Pesakit berada di bilik berhampiran. Apakah yang patut dilakukan oleh jururawat selepas membunyikan penggera?

1. ACuba memadamkan api yang merebak seorang diri dengan pemadam api
2. BMembuka semua pintu dan tingkap supaya asap keluar
3. CMenutup pintu dan memindahkan pesakit yang berada dalam bahaya secara mendatar di sebalik pintu kebakaran
4. DMembawa pesakit ke tingkat bawah menggunakan lif yang terdekat

Paras palung vankomisin berada di atas julat sasaran. Kesan advers manakah yang menjadi kebimbangan utama?

1. AGlukosa darah rendah (hipoglisemia)
2. BSembelit dan kembung perut
3. CKerosakan buah pinggang (nefrotoksisiti)
4. DKiraan platelet yang meningkat (trombositosis)

A patient with a round face, central weight gain and purple stretch marks has a glucose of 210 mg/dL (11.7 mmol/L) and a potassium of 3.1 mEq/L. Which condition fits best?

1. ADiabetes insipidus
2. BAdrenal insufficiency
3. CCushing syndrome
4. DHypothyroidism

A patient says they are "allergic" to codeine because it made them constipated. How should this be recorded?

1. AAs a severe anaphylactic allergy to all opioids
2. BAs an allergy to all painkillers
3. CIt should not be recorded at all
4. DAs a side effect or intolerance, not a true allergy

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

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

A patient with heart failure is comfortable at rest but becomes breathless walking across a room. Which NYHA class fits best?

1. AClass IV
2. BClass II
3. CClass III
4. DClass I

Semasa serangan asma teruk, PaCO₂ pesakit meningkat daripada rendah kepada normal sementara pesakit kelihatan keletihan. Apakah maksudnya?

1. ASampel itu mungkin vena dan boleh diabaikan
2. BSerangan sedang reda dan rawatan boleh dikurangkan
3. CPesakit semakin letih dan kegagalan pernafasan mungkin menyusul
4. DPesakit bernafas laju kerana kebimbangan

A man starts tamsulosin for BPH. Which teaching point is most important?

1. AExpect the drug to shrink the prostate within a day
2. BTake it with grapefruit juice to make it work better
3. CStop it if the urine stream improves
4. DStand up slowly, because it can make you dizzy

A patient arrives five hours after the onset of a stroke. A CT angiogram shows a blockage of a large artery in the brain. What is the most appropriate next step?

1. AUrgent referral for assessment for mechanical thrombectomy
2. BNo treatment, because the time for any reperfusion has passed
3. CGive aspirin and plan a review on the ward tomorrow
4. DStart IV alteplase immediately without further imaging

In the SBAR communication tool, what belongs under "A"?

1. AThe nurse's assessment of what the problem is
2. BThe patient's admission date only
3. CThe address and phone number of the patient's next of kin
4. DA list of the patient's allergies only

A patient finds daily wound dressing changes very painful. What is the most effective nursing approach?

1. ADo the dressing quickly and give analgesia afterwards
2. BAvoid analgesia so the patient can report any problems during the change
3. CGive analgesia timed so it works during the dressing change
4. DChange the dressing less often than the plan says