Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A patient with a spinal cord injury at T4 suddenly has a severe headache, flushing above the injury and a blood pressure of 200/110 mmHg. What does the nurse do first?

1. ASit the patient upright with the legs lowered
2. BApply extra blankets to keep the patient warm and calm
3. CLay the patient flat with the legs raised
4. DGive a warm drink and recheck the blood pressure in an hour

Tugas manakah yang paling sesuai dilakukan sendiri oleh RN dan bukan didelegasikan kepada pembantu jururawat?

1. AMenimbang pesakit kegagalan jantung setiap pagi
2. BMembawa pesakit yang stabil berjalan di koridor pada hari ketiga selepas pembedahan
3. CMengeluarkan pesakit dari katil buat kali pertama selepas pembedahan
4. DMembantu pesakit dengan penjagaan mulut

A patient receiving continuous nasogastric feeding has pulled the tube partly out. What should the nurse do first?

1. APush the tube back in and restart the feed
2. BStop the feeding until the tube position is checked
3. CTape the tube in its new position and continue
4. DIncrease the feed rate to make up for the lost time

According to the “Swiss cheese” model of error, why do errors reach patients?

1. AWeaknesses in several layers of defense line up at the same time
2. BTechnology fails more often than people do
3. CPatients often do not follow their care instructions
4. DOne careless person makes a mistake that no system could stop

Seorang pesakit yang mengambil digoksin mempunyai paras 2.8 ng/mL dan kadar denyutan jantung 52/min. Apakah tindakan terbaik jururawat?

1. ATahan dos dan maklumkan pemreskripsi
2. BBeri dos dan semak semula paras dalam sebulan
3. CBeri dos, kerana kadar denyutan jantung melebihi 50/min
4. DBeri dos berganda untuk membetulkan irama

A patient has fever, chills, flank pain and costovertebral angle tenderness. Urinalysis shows many white cells and white cell casts. Which condition is most likely?

1. AAcute pyelonephritis
2. BSimple cystitis
3. CGlomerulonephritis
4. DNephrotic syndrome

Seorang pesakit mengalami sakit abdomen berkolik, abdomen bengkak, muntah dan tidak melepaskan najis atau angin selama dua hari. Apakah masalah yang mungkin?

1. AGastroenteritis
2. BHalangan usus
3. CSindrom usus mudah rangsang
4. DApendisitis tanpa komplikasi

A patient suddenly develops a painful red eye with blurred vision, haloes around lights and vomiting. What should be suspected?

1. AAcute angle-closure glaucoma
2. BDry eye syndrome
3. CSimple conjunctivitis from a viral infection
4. DA stye

Why should a long-acting beta-2 agonist (LABA) never be used alone in asthma?

1. AIt always causes immediate severe bronchospasm when used on its own
2. BWithout an inhaled steroid, it is linked with severe and fatal attacks
3. CIt cannot be inhaled without a nebuliser
4. DIt works only when it is taken together with a course of antibiotics

During a thrombolytic infusion for an MI, the patient develops a sudden severe headache, vomiting and new confusion. What should the nurse do first?

1. AContinue the infusion, as headache is a common side effect
2. BStop the infusion and call for urgent medical help
3. CSlow the infusion and give an antiemetic
4. DGive a second dose to finish the treatment

Sawan telah berlangsung lima minit dan masih berterusan. Apakah rawatan ubat barisan pertama yang biasa?

1. AAdrenalin IM ke dalam paha luar
2. BDos pemuat fenitoin IV sebelum apa-apa yang lain
3. CBenzodiazepin seperti lorazepam IV atau midazolam bukal
4. DGlukosa 50% IV pada setiap pesakit, kemudian nilai semula

Two days after an ileal conduit was formed, the stoma is dark purple and dry. What should the nurse do?

1. AApply a warm compress to improve the colour of the stoma
2. BReport it urgently, because the stoma may be ischaemic
3. CRecord it as normal for a new stoma
4. DChange the bag and check again next week

Which advice may help reduce the risk of a parastomal hernia after stoma surgery?

1. AAvoid heavy lifting early on and use support garments as advised
2. BDo intensive sit-ups from the first week
3. CStrain hard on the toilet each day to strengthen the abdominal muscles
4. DKeep the stoma bag as full as possible

A patient with a sacral pressure ulcer keeps sliding down the bed when the head is raised high. Which advice best reduces shear?

1. ASit the patient upright without any support for the feet
2. BRaise the head of the bed to 90° and pull the patient up the bed by the arms
3. CKeep the head of the bed at or below 30° if possible; use slide sheets
4. DUse a dry sheet and drag the patient up the bed