Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Which postoperative patient should the nurse see first?

1. APain of 4/10 one hour after an oral analgesic
2. BAsking when the urinary catheter will be removed
3. CDressing soaked with bright red blood and a heart rate rising to 118/min
4. DWants help with washing her hair before her visitors arrive this afternoon

After a head injury, a patient passes large amounts of very dilute urine, is thirsty and has a rising serum sodium. Which condition is most likely?

1. ASIADH
2. BDiabetic ketoacidosis
3. CDiabetes insipidus
4. DAcute kidney injury with oliguria

How should a portable oxygen cylinder be kept in a patient’s room?

1. ALying loose on the floor beside the bed
2. BLaid on the bed next to the patient
3. CPlaced next to a heater to keep it warm
4. DSecured upright in a stand or holder

A nurse sees a doctor about to insert a central line without a sterile gown, and a polite comment was ignored. Which TeamSTEPPS phrase helps to stop the procedure?

1. A“I will mention this to the manager at the next staff meeting.”
2. B“I am concerned, I am uncomfortable, this is a safety issue.”
3. C“I am sure you know what you are doing.”
4. D“Let’s talk about it after you have finished.”

A patient's eGFR has fallen to 24 mL/min/1.73 m². Which prescribed drug should the nurse question before giving it?

1. ALevothyroxine
2. BMetformin
3. CInsulin glargine
4. DAcetaminophen (paracetamol)

A patient with a stable INR on warfarin starts rifampin (rifampicin) for tuberculosis. Two weeks later the INR is 1.3. What is the most likely explanation?

1. ARifampin raises the INR, so it is wrong
2. BTuberculosis causes the INR to fall
3. CRifampin speeds up warfarin metabolism
4. DRifampin contains a lot of vitamin K

A very anxious patient breathes rapidly for a long period. Which change is expected?

1. AMetabolic alkalosis from vomiting
2. BMetabolic acidosis from a low bicarbonate
3. CRespiratory acidosis from a high PaCO₂
4. DRespiratory alkalosis from a low PaCO₂

An adult with capacity refuses a blood transfusion for religious reasons, even though it may save their life. What should the nurse do?

1. AAsk a family member to consent instead
2. BRespect the refusal, check it is informed and document it, and inform the team
3. CSedate the patient so the transfusion can be given
4. DGive the transfusion while the patient is asleep, as it is in their best interests

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 28-year-old woman taking the combined pill comes in breathless and anxious. RR is 30/min, heart rate 118/min and SpO₂ 90% on air. A colleague says it is a panic attack. What should the nurse conclude?

1. AShe should be sent home after a sedative
2. BBreathing into a paper bag is the best first treatment for her
3. CLow oxygen saturation is not explained by anxiety; PE must be excluded
4. DThe saturation is normal for an anxious person who is breathing fast

Which group of drugs is a well-known cause of SIADH and hyponatraemia, especially in older people?

1. ASSRI antidepressants
2. BBulk-forming laxatives
3. CPenicillin antibiotics
4. DProton pump inhibitors

After removal of a cortisol-producing adrenal adenoma, why may the patient need hydrocortisone for months?

1. AThe other adrenal gland has been suppressed
2. BThe operation always removes both adrenal glands
3. CHydrocortisone helps the wound to heal
4. DThe tumour will grow back quickly without it

Which rule about the sterile field is correct?

1. AIf sterility is in doubt, the item is treated as contaminated
2. BSterile items can be passed across a non-sterile area freely
3. CA sterile pack stays sterile even when it is wet
4. DThe area below a gowned person's waist is sterile

A colleague suggests giving a saline injection to see whether a patient's pain is "real". What is the best response?

1. AIt should be done only for patients with chronic pain
2. BIt is a good idea, as long as the patient is not told about it afterwards
3. CDeceptive placebos are unethical and do not show pain is "fake"
4. DIt is acceptable if a senior nurse gives the saline