Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A patient taking lisinopril develops swelling of the lips and tongue. What should the nurse do first?

1. AGive the next dose of lisinopril with water
2. BAssess the airway and call for urgent help
3. CTell the patient this is a common, harmless effect
4. DApply a cold pack and recheck in an hour

Seorang pesakit yang diselamatkan daripada kebakaran rumah mempunyai lecur pada muka, bulu hidung hangus dan suara serak. Apakah keutamaannya?

1. AMemulakan resusitasi cecair IV yang dikira daripada saiz lecur
2. BMemberi pelega sakit
3. CMelindungi saluran udara, bersedia untuk sokongan saluran udara awal
4. DMembersihkan dan membalut lecur muka

Sebelum memberikan tablet, pesakit berkata, “Pil ini kelihatan berbeza daripada yang biasa saya makan.” Apakah yang patut dilakukan oleh jururawat?

1. AMemberitahu pesakit bahawa semua pil kelihatan berbeza di hospital
2. BBerhenti dan semak semula arahan serta ubat sebelum memberikannya
3. CMenenangkan pesakit dan memberikan pil itu
4. DMemberikan separuh pil dan memerhatikan sebarang kesan luar biasa

A nurse has a needlestick from a patient known to have hepatitis C. Which statement about management is correct?

1. AThe hepatitis C vaccine series is started at once, with a booster dose six months later
2. BThere is no preventive drug, so baseline and follow-up testing are done to detect infection early
3. CHepatitis C immune globulin is given within 24 hours, followed by a booster dose
4. DNo follow-up is needed because hepatitis C does not spread by needles

A urine culture report states "mixed growth of three organisms, likely contamination." What is the nurse's best response?

1. AStart treatment for all three organisms with three antibiotics
2. BInform the provider and arrange a new, correctly collected sample
3. CDiscard the report, because a mixed growth is always normal
4. DRecord the result as a confirmed urinary tract infection

Seorang pesakit yang mengambil diuretik tiazid mempunyai natrium 129 mEq/L, kalium 3.2 mEq/L dan berasa lemah. Penjelasan manakah yang paling sesuai?

1. AKeputusan ini tipikal bagi kegagalan buah pinggang
2. BPesakit menghidap hiperaldosteronisme primer dengan natrium tinggi
3. CDiuretik menyebabkan kehilangan natrium dan kalium
4. DPesakit mengalami lebihan cecair daripada cecair IV sahaja

Abdomen pesakit keras seperti papan, dan mereka berbaring sangat diam kerana pergerakan memburukkan sakit. Apakah yang dicadangkan oleh ini?

1. ASembelit
2. BJangkitan saluran kencing
3. CSenak
4. DPeritonitis

Seorang pesakit dengan trakeostomi tiba-tiba tidak dapat bernafas dan tiub kelihatan tersumbat. Apakah tindakan pertama?

1. AKempiskan kaf dan tinggalkan pesakit
2. BTunggu doktor sebelum melakukan apa-apa
3. CKeluarkan tiub dalam (kanula) dan periksa sama ada ia tersumbat
4. DBeri oksigen melalui mulut sahaja

A patient is starting doxazosin, an alpha-blocker, for hypertension. Which advice is most important?

1. ATake it with a large glass of grapefruit juice to improve absorption
2. BAvoid all potassium-containing foods
3. CTake the first dose at bedtime, as dizziness and fainting can occur
4. DStop it suddenly if the heart rate rises after the first few doses

Pada hari ke-6 infusi heparin, kiraan platelet telah turun lebih separuh dan pesakit mengalami lengan bengkak yang baharu. Apakah yang patut dijangka oleh jururawat?

1. AMenghentikan semua antikoagulasi selama dua minggu
2. BMenghentikan semua heparin dan memulakan antikoagulan bukan heparin
3. CMeneruskan heparin dan memberikan pemindahan platelet
4. DBertukar kepada LMWH kerana ia ubat yang berbeza

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

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

A student has fever, a severe headache, a spreading non-blanching rash and a BP of 85/50 mmHg. A lumbar puncture is planned. What is the priority?

1. AGive paracetamol (acetaminophen) and recheck observations in an hour
2. BGive IV antibiotics at once and start sepsis treatment
3. CArrange a CT scan of the head before any treatment
4. DWait until after the lumbar puncture before giving antibiotics

A patient takes co-codamol at home (a combination tablet sold under different names in different countries). Why should the nurse check this before giving regular paracetamol (acetaminophen)?

1. AIt already contains paracetamol, so overdose could occur
2. BParacetamol and codeine cause a severe allergic reaction when combined
3. CCo-codamol stops paracetamol from working
4. DCo-codamol must be stopped a week before any paracetamol

A nurse teaches a patient about a fentanyl skin patch. Which statement shows a need for further teaching?

1. A"I'll put the new patch on a different area of skin."
2. B"I won't put a hot water bottle over the patch."
3. C"I'll fold used patches sticky sides together before disposal."
4. D"I can cut the patch in half if I need less."