Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A patient on hemodialysis has an arteriovenous fistula in the left arm. Which instruction should the nurse give the nursing assistant?

1. AMeasure blood pressure on the left arm only, every 4 hours
2. BHelp the patient carry shopping bags on the left arm
3. CDo not measure blood pressure on the left arm
4. DKeep the left arm wrapped tightly in a bandage at night

An older patient with heart failure is receiving a second unit of blood. She becomes breathless, with crackles in both lungs and a rising blood pressure. What is most likely happening?

1. ATransfusion-associated circulatory overload
2. BAn expected effect of the first unit
3. CHypoglycemia caused by the stored blood product
4. DA mild allergic reaction with hives

When is it appropriate to use the override function on an automated dispensing cabinet to take a drug before pharmacist review?

1. AWhenever the nurse is sure of the dose
2. BAt the start of each shift to save time later
3. COnly in an urgent situation where delay would harm the patient, per policy
4. DWhenever the pharmacist is slow to review new orders and the patient is waiting

A nursing student describes how they remove PPE (gown, gloves and a mask worn for splash protection) at the doorway before leaving a contact precautions room. Which statement shows a need for further teaching?

1. A“I remove my gloves without touching the outside with my bare hand.”
2. B“I roll the gown inward as I take it off.”
3. C“I clean my hands as soon as all the PPE is off.”
4. D“I take off my mask first, and then I take off my gloves.”

A patient with chronic kidney disease has a potassium of 5.6 mEq/L. Which food should the nurse advise the patient to limit?

1. AWhite rice
2. BCabbage
3. CBananas
4. DApples

The nurse teaches a patient about the HbA1c test. Which statement shows a need for further teaching?

1. A"A lower result means less risk of damage to my eyes and kidneys"
2. B"My daily finger-stick readings still matter between the tests"
3. C"The test shows my average glucose over the past few months"
4. D"I must not eat anything for 12 hours before the HbA1c test"

Semasa memberi insulin, pernyataan manakah yang betul?

1. AInsulin bertindak pantas diberikan pada waktu tidur sahaja
2. BGilirkan tapak suntikan untuk mengelakkan lipohipertrofi
3. CInsulin patut digoncang kuat sebelum digunakan
4. DSentiasa suntik pada tempat yang sama untuk penyerapan yang konsisten

A catheterised postoperative patient has passed only 10 mL of urine in the last two hours. What should the nurse check first?

1. AWhether the patient has eaten breakfast
2. BThe patient's weight from last year
3. CThat the catheter and tubing are not kinked or blocked
4. DThe patient's cholesterol level from the admission bloods

How does ezetimibe lower cholesterol?

1. AIt increases cholesterol loss in the urine
2. BIt reduces absorption of cholesterol from the gut
3. CIt dissolves plaques already in the arteries
4. DIt blocks cholesterol production by enzymes in the liver

Seorang pesakit COPD sesak nafas dengan SpO₂ 84% pada udara bilik. Gas darah menunjukkan pH 7.30 dan PaCO₂ yang meningkat walaupun rawatan perubatan optimum. Rawatan manakah yang mungkin dipertimbangkan?

1. AOksigen kepekatan tinggi melalui pelitup muka bukan-sedut-semula
2. BPengudaraan tidak invasif (NIV)
3. CSedasi IV untuk memperlahankan kadar pernafasan
4. DMenghentikan bronkodilator nebulisasi

Seorang pesakit AKI mempunyai kateter urin yang tidak mengalirkan apa-apa. Semakan pantas di sisi katil manakah yang membantu menyingkirkan punca pascarenal?

1. AMenggalakkan pesakit minum dua liter air
2. BMenghantar sampel air kencing untuk kultur dan menunggu keputusan makmal
3. CMemeriksa kateter untuk lipatan atau sekatan dan melakukan imbasan pundi kencing
4. DMemberikan bolus besar cecair IV serta-merta

Seorang pesakit yang mengambil litium mengalami poliuria dan dahaga, dan air kencing tidak memekat selepas desmopresin. Apakah punca yang paling mungkin?

1. ADI nefrogenik disebabkan oleh litium
2. BDiabetes jenis 1 yang baru berkembang
3. CSIADH disebabkan oleh litium
4. DDI kranial selepas kecederaan kepala

Which patient is at highest risk of refeeding syndrome?

1. AA patient with a normal BMI eating three meals a day
2. BAn underweight patient who has eaten very little for 10 days
3. CA patient who missed one lunch because of a scan
4. DA healthy adult after an overnight fast for minor surgery

Two days after a PEG insertion, a patient reports pain on feeding, and feed is leaking around the site. What should the nurse do?

1. AIncrease the feed rate to improve nutrition
2. BStop the feed at once and seek urgent medical advice
3. CContinue feeding and apply a thicker dressing
4. DGive the next medicines through the tube as usual