Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A child with fever and headache develops a purple rash that does not fade when pressed with a glass. What should the nurse do?

1. AApply a soothing cream to the rash
2. BAdvise the family to see their doctor next week
3. CGive acetaminophen (paracetamol) and reassess in four hours
4. DTreat it as an emergency and escalate at once

Di unit kardiak, pesakit manakah yang patut dilihat dahulu oleh jururawat?

1. APesakit fibrilasi atrium yang kadar denyutan jantungnya 88/min dan tidak teratur, seperti sebelumnya
2. BPesakit kegagalan jantung yang bertambah 0.3 kg sejak semalam
3. CPesakit yang diminta berpuasa sebelum imbasan esok
4. DPesakit yang mengambil digoksin dengan nadi 48/min, loya dan kalium 3.0 mEq/L

A nurse who wears prescription glasses must irrigate a wound where splashing is likely. Which eye protection is suitable?

1. AGoggles or a face shield worn over the glasses
2. BThe glasses with a surgical mask
3. CNo eye protection, if the nurse stands to one side
4. DThe prescription glasses alone

A patient dies after a wrong-drug error, and the hospital carries out a root cause analysis. What is its main focus?

1. AFinding the system and process weaknesses that allowed the error
2. BDeciding whether to tell the family about the error
3. CEstimating the legal costs for the hospital
4. DIdentifying which staff member made the error and should be disciplined

Sebelum memberi kalium klorida IV yang ditetapkan, penilaian manakah yang paling penting?

1. APendengaran di kedua-dua telinga
2. BSaiz anak mata dan tindak balas terhadap cahaya
3. CTurgor kulit pada lengan bawah
4. DKeluaran air kencing dan fungsi buah pinggang

A patient on clozapine for 2 years has been stable. Which statement shows a need for further teaching?

1. A"I'll tell other doctors that I take clozapine"
2. B"I can stop my blood tests since I feel well"
3. C"I'll keep all my scheduled blood test visits"
4. D"I'll report a sore throat or fever at once"

In UK guidance, neutropenic sepsis is commonly defined by a temperature above 38 °C or signs of sepsis with a neutrophil count at or below:

1. A15 × 10⁹/L
2. B150 × 10⁹/L
3. C5 × 10⁹/L
4. D0.5 × 10⁹/L

Pesakit dengan pendarahan GI akut mempunyai kadar jantung 120/min dan tekanan darah 90/60 mmHg. Apakah keutamaan kejururawatan selepas memanggil bantuan?

1. ATangguhkan tindakan sehingga warna najis disemak
2. BGalakkan berjalan ke bilik air bersendirian
3. CDapatkan akses IV bergarisan besar dan sediakan untuk penggantian cecair atau darah
4. DBeri hidangan besar untuk memulihkan tenaga

A patient's capillary refill time at the fingertip is 4 seconds. What does this suggest?

1. AReduced peripheral perfusion
2. BAn unusually strong cardiac output
3. CNormal peripheral perfusion
4. DA high haemoglobin level

A patient with a stab wound to the chest has a hole that sucks air with each breath. What is the immediate management?

1. ASeal it completely with tape on all four sides and leave it alone
2. BLeave it open and give a nebuliser
3. CPack the wound tightly with gauze pushed deep into the chest
4. DCover it with a vented chest seal or a dressing taped on three sides

After a lumbar discectomy, which finding should the nurse report promptly?

1. AMild pain at the wound site
2. BNew weakness or numbness in the legs
3. CA dry, intact wound dressing
4. DStiffness when getting out of bed

A kidney transplant recipient has had vomiting and diarrhoea for two days. Why should the transplant team be contacted?

1. AThe patient may not be absorbing their immunosuppressants
2. BThe tablets will make the vomiting stop
3. CVomiting proves that rejection has already happened
4. DThe kidney will start to produce far too much urine

Why is pethidine (meperidine) generally avoided for regular pain relief?

1. AIt can only be given by mouth
2. BIt always causes severe diarrhoea
3. CIt has no pain-relieving effect at all in adults
4. DA metabolite can build up and cause seizures

A nurse teaches a patient going home between chemotherapy cycles. Which statement shows a need for further teaching?

1. A"I'll check my temperature whenever I feel hot, shivery or unwell."
2. B"If I get a fever, I'll take paracetamol and see if it settles."
3. C"I'll keep the emergency number and call if I feel shivery."
4. D"I'll wash my hands often and avoid people with infections."