Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A young adult has just started an SSRI antidepressant for major depression. What should the nurse monitor most closely in the first weeks?

1. AWeight loss from too much appetite
2. BHair growth and skin color
3. CThoughts of suicide or self-harm
4. DRising blood glucose levels

Which patient with cirrhosis should the nurse see first?

1. AVomiting bright red blood, heart rate 120/min
2. BWants to talk about stopping drinking alcohol for good
3. CLong-standing jaundice and itchy skin, asking for cream
4. DLarge ascites that is unchanged from yesterday

Which practice is safe when transferring a patient from a bed to a stretcher?

1. ALeave the stretcher wheels unlocked so it can move with the patient
2. BHave the patient slide across without help or a slide sheet
3. CLower the stretcher side rails during transport
4. DLock the wheels of both the bed and the stretcher before moving the patient

Which action by assistive personnel requires the nurse to step in?

1. APutting soiled linen straight into a laundry bag at the bedside
2. BWashing hands with soap and water after leaving a C. difficile room
3. CRemoving gloves and then cleaning the hands with alcohol rub
4. DGoing from one patient’s bed to the next while wearing the same gloves

A patient receiving chemotherapy has an ANC of 300/µL and a new temperature of 38.3 °C (100.9 °F). What should the nurse do first?

1. AReport it at once so cultures and antibiotics start quickly
2. BGive acetaminophen (paracetamol) and recheck the temperature in 4 hours
3. CRemove extra blankets and offer a tepid sponge bath
4. DEncourage oral fluids and record the fever in the chart

A patient without diabetes in the ICU with sepsis has a glucose of 260 mg/dL (14.4 mmol/L) and an HbA1c of 5.2%. What is the best interpretation?

1. AStress hyperglycemia from acute illness
2. BA meter error, because HbA1c is normal
3. CType 1 diabetes from autoimmune damage
4. DLong-standing undiagnosed type 2 diabetes

Penilaian manakah yang paling baik mengesan sindrom petak selepas kaki patah dibalut dengan simen (cast)?

1. AKaki yang hangat dan merah jambu
2. BSakit yang tidak setimpal dengan kecederaan, terutamanya pada regangan pasif
3. CGatal ringan di bawah simen
4. DDenyutan kuat di kaki

Which task is most appropriate for a registered nurse to delegate to a trained healthcare assistant (unlicensed assistive personnel)?

1. AGiving a dose of intravenous antibiotic
2. BMeasuring and recording vital signs on a stable patient
3. CAssessing a patient who has just reported new chest pain
4. DTeaching a patient to inject insulin for the first time

Which skin changes around the ankles are typical of chronic venous insufficiency?

1. APale, shiny, hairless skin with weak pulses
2. BA sharply defined red patch with fever
3. CBrown staining, swelling and dry, itchy skin
4. DA cold, white foot with no pulse

A hypotensive patient has a temperature of 39.2 °C, warm flushed skin, a bounding pulse and a fast heart rate. Which type of shock is most likely?

1. ACardiogenic shock
2. BEarly septic (distributive) shock
3. CObstructive shock from tamponade
4. DHypovolaemic shock from bleeding

A patient with a suspected basal skull fracture needs a gastric tube. Which route is preferred?

1. AThrough a fine-bore nasal tube
2. BThrough the mouth (orogastric)
3. CThrough the nose (nasogastric)
4. DThrough the nose with a guidewire

Seorang wanita dengan epilepsi yang mengambil valproat berkata dia merancang kehamilan. Respons manakah yang paling sesuai?

1. AMenasihati supaya tidak menghentikannya secara tiba-tiba dan semakan pakar segera
2. BMenyuruhnya berhenti mengambil valproat sepenuhnya mulai hari ini
3. CMencadangkan menggandakan dos untuk melindungi bayi daripada sawan
4. DMenenangkannya bahawa valproat selamat sepanjang kehamilan

Which lifestyle change most improves the course of Crohn's disease?

1. AStopping smoking
2. BEating more red meat
3. CDrinking more coffee
4. DAvoiding all exercise

A patient with a leg ulcer has an ABPI of 0.5. The doctor's plan mentions starting strong compression bandages. What should the nurse do?

1. AApply compression and elevate the leg above the heart all day
2. BApply compression but only at night
3. CApply the strongest compression to speed healing
4. DWithhold strong compression and discuss urgent vascular referral