Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Semasa triaj START, seorang dewasa yang tidak boleh berjalan bernafas 22 kali seminit, mempunyai nadi radial dan mengikut arahan mudah, tetapi mempunyai patah kaki yang jelas. Kategori manakah yang diberikan kepada mangsa itu?

1. AKuning (ditangguhkan)
2. BHijau (kecil)
3. CMerah (segera)
4. DHitam (dijangka maut)

Pendelegasian manakah yang sesuai untuk pembantu jururawat?

1. AMemantau pesakit semasa 15 minit pertama pemindahan darah
2. BMemeriksa tiub nasogastrik yang baru dipasang sebelum pemberian makanan pertama
3. CMengumpul spesimen air kencing rutin daripada pesakit yang stabil
4. DMemberi hidangan pertama kepada pesakit yang penelanannya belum disaring selepas strok

Which part of a sterile surgical gown is considered sterile once it is on?

1. AThe whole gown, including the back, the collar and the area below the waist
2. BOnly the back of the gown, which nobody touches
3. CThe front from chest to the level of the sterile field, and the sleeves
4. DThe front from the neck down to the knees

In START triage at a mass-casualty incident, a casualty cannot walk, breathes 20 times a minute, has a radial pulse and follows simple commands. Which category applies?

1. ABlack (expectant or dead)
2. BGreen (minor)
3. CYellow (delayed)
4. DRed (immediate)

A patient who is breathless during a transfusion has hypotension, fever and bilateral lung infiltrates, with no signs of fluid overload. Which complication is most likely?

1. ATransfusion-related acute lung injury (TRALI)
2. BTransfusion-associated circulatory overload
3. CA mild febrile nonhemolytic reaction
4. DA simple allergic reaction with hives

Weeks after neck surgery, a patient has muscle cramps and tingling. Calcium is low, phosphate is high and parathyroid hormone (PTH) is low. Which condition fits best?

1. APrimary hyperparathyroidism
2. BHypoparathyroidism
3. CChronic kidney disease
4. DVitamin D toxicity

Which measure helps prevent delirium in older inpatients?

1. AReorientation, glasses and hearing aids in use, and good sleep and hydration
2. BKeeping the lights on all night
3. CMoving the patient to a different bed each night to give them a change of scene
4. DRestricting fluids to avoid incontinence

Soon after starting chemotherapy for a high-grade lymphoma, a patient has rising potassium, phosphate and uric acid with falling urine output. What is the most likely cause?

1. AAdrenal insufficiency
2. BTumour lysis syndrome
3. CSyndrome of inappropriate ADH secretion
4. DRefeeding syndrome

Why must anti-embolism stockings be measured and fitted correctly?

1. APoorly fitting stockings can cause pressure damage
2. BLoose stockings make the patient's legs too warm at night
3. CTight stockings work better, so the smallest size is always best
4. DCorrect fit is needed only to improve the appearance

Which method best confirms that an endotracheal tube is in the trachea?

1. AA sustained waveform on capnography
2. BThe chest rising on one side only
3. CMisting inside the tube
4. DThe patient's skin colour improving

Bagaimanakah tekanan perfusi serebrum (CPP) dikira?

1. ATekanan diastolik tolak tekanan vena pusat
2. BTekanan arteri min dibahagi dengan kadar jantung
3. CTekanan arteri sistolik campur tekanan intrakranial
4. DTekanan arteri min tolak tekanan intrakranial

Why might a frail 88-year-old with type 2 diabetes have a less strict HbA1c target?

1. ABecause older people cannot use any glucose medicines
2. BBecause diabetes cannot damage older people
3. CTo reduce the risk of hypos, falls and confusion
4. DTo save money on blood tests and drugs

Which advice helps a patient with haemorrhoids?

1. ASit on the toilet for long periods to empty fully
2. BEat more fibre, drink enough fluid and avoid straining
3. CEat less fibre so that stools are smaller
4. DTake a codeine-based painkiller every day

A 62-year-old with known reflux reports burning central chest pain with sweating and breathlessness that began while walking. What should the nurse do first?

1. ARecord a 12-lead ECG and escalate as possible cardiac pain
2. BBook a routine endoscopy for later in the week
3. CGive an antacid and reassess the pain in an hour
4. DAdvise the patient to avoid spicy food at future meals