Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Lembaran formula, langkah kaedah utama untuk setiap topik dan 14 soalan latihan, dengan penyelesaian penuh di bahagian belakang.

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1Formula dan kaedah

Pemberian keutamaan & delegasi

Kaedah

  1. Tanya apa yang akan membahayakan pesakit paling cepat jika tiada apa-apa dilakukan.
  2. Gunakan ABC (C-A-B dalam henti jantung), kemudian Maslow: keperluan fisiologi sebelum keselamatan, keselamatan sebelum keperluan psikologi.
  3. Bandingkan pilihan: akut sebelum kronik, tidak stabil sebelum stabil, tidak dijangka sebelum dijangka, sistemik sebelum setempat, dan semak setiap penemuan dengan garis dasar pesakit.
  4. Nilai sebelum bertindak kecuali dalam kecemasan; kemudian pilih langkah yang menjadi tempat bergantung langkah-langkah lain.
  5. Untuk delegasi, semak lima hak: tugas, keadaan, orang, arahan dan penyeliaan. Penilaian, pengajaran dan penilaian semula kekal pada RN.

Kawalan jangkitan & keselamatan pesakit

Kaedah

  1. Mulakan dengan langkah berjaga-jaga standard untuk setiap pesakit: kebersihan tangan, PPE untuk pendedahan yang dijangka, benda tajam yang selamat.
  2. Tambah langkah berjaga-jaga mengikut laluan: sentuhan (gaun, sarung tangan), titisan (pelitup muka pembedahan), bawaan udara (N95, bilik tekanan negatif).
  3. Pastikan item steril kekal steril: jika ragu-ragu, ia tidak steril; gantikan, jangan sekali-kali dilap.
  4. Cegah bahaya dalam persekitaran: langkah pencegahan jatuh, sekatan hanya sebagai pilihan terakhir, RACE dan PASS untuk kebakaran.
  5. Semak hak pemberian ubat, dua pengenalpastian dan perlindungan tambahan untuk ubat berisiko tinggi; laporkan kesilapan dan hampir-hampir terlepas.

Nilai makmal & elektrolit

Kaedah

  1. Bandingkan nilai dengan julat rujukan makmal itu sendiri, kemudian dengan garis dasar dan arah aliran pesakit.
  2. Semak sampel: hemolisis, kelewatan, atau darah yang diambil berhampiran IV boleh memberikan keputusan palsu.
  3. Kaitkan nilai dengan tanda lazimnya dan dengan ubat serta keadaan yang menyebabkannya.
  4. Cari interaksi: kalium atau magnesium yang rendah meningkatkan ketoksikan digoksin; dehidrasi menaikkan litium.
  5. Bertindak untuk pesakit: nilai, tahan ubat jika paras tidak selamat, baca balik nilai kritikal dan maklumkan pemberi preskripsi.

Perubatan-pembedahan: kardiovaskular & respiratori

Kaedah

  1. Namakan masalah itu: kegagalan pam, arteri tersumbat, rentak, bekuan, penyempitan saluran udara, jangkitan atau masalah peranti.
  2. Semak tanda bahaya dahulu: hipoksia, hipotensi, sakit dada, kekeliruan baharu, anggota sejuk tanpa nadi.
  3. Padankan oksigen dengan pesakit: 94–98% untuk kebanyakan, 88–92% untuk mereka yang berisiko menahan CO₂.
  4. Kaitkan setiap ubat dengan ujian dan risikonya: warfarin dan INR, heparin dan aPTT serta platelet, diuretik dan kalium.
  5. Pilih tindakan pertama yang selamat, kemudian eskalasikan dan nilai semula.

Perubatan-pembedahan: neurologi, endokrin & renal

Kaedah

  1. Semak glukosa pada setiap pesakit dengan kekeliruan baharu, kelemahan atau sawan.
  2. Gunakan tahap kesedaran sebagai amaran paling awal masalah otak; pupil dan triad Cushing muncul lewat.
  3. Untuk kecemasan diabetes, bezakan DKA (keton, asidosis) daripada HHS (osmolaliti yang sangat tinggi, dehidrasi); berikan cecair dahulu.
  4. Untuk natrium dan air, tentukan sama ada ADH berlebihan (SIADH) atau tiada (DI), dan betulkan perubahan kronik secara perlahan.
  5. Untuk masalah buah pinggang, asingkan puncanya kepada pra-renal, intrinsik atau pasca-renal, dan pantau kalium dan cecair.

Perubatan-pembedahan: GI, perioperatif & onkologi

Kaedah

  1. Tanya apa yang mungkin tersembunyi: pendarahan dalaman, jangkitan tanpa demam, hipoventilasi di sebalik SpO₂ yang normal.
  2. Gunakan masa selepas pembedahan untuk mengecilkan komplikasi: pendarahan dalam beberapa jam, masalah dada dalam beberapa hari, masalah luka dan kebocoran kemudian.
  3. Untuk kesakitan, nilai, rawat dengan analgesia multimodal, nilai semula, dan pantau sedasi dengan setiap opioid.
  4. Untuk pesakit kanser, anggap sebarang penyakit semasa nadir sebagai sepsis neutropenik dan ketahui kecemasan onkologi.
  5. Untuk luka bakar, kira hanya kawasan ketebalan separa dan penuh, mulakan jam Parkland pada masa terbakar dan laraskan mengikut keluaran air kencing.

2Soalan latihan

1.Pemberian keutamaan & delegasiSederhana

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

  1. AHelp the patient carry shopping bags on the left arm
  2. BKeep the left arm wrapped tightly in a bandage at night
  3. CMeasure blood pressure on the left arm only, every 4 hours
  4. DDo not measure blood pressure on the left arm
2.Pemberian keutamaan & delegasiSukar

After surgery, a patient who has taken long-term steroids becomes hypotensive and weak, and the blood pressure does not rise with IV fluids. Which problem should the nurse suspect?

  1. AAdrenal crisis from steroid withdrawal
  2. BNormal tiredness after anesthesia
  3. CFluid overload from too much IV fluid
  4. DAn allergic reaction to the anesthetic
3.Kawalan jangkitan & keselamatan pesakitSederhana

A patient in bed has a generalized tonic-clonic seizure. What should the nurse do?

  1. APut a padded tongue blade between the teeth to protect the tongue from biting
  2. BHold the arms and legs firmly to stop the movements
  3. CTurn the patient on their side and protect them from injury without restraining
  4. DGive sips of water to keep the airway moist
4.Kawalan jangkitan & keselamatan pesakitSukar

Seorang pesakit pernah mengalami MRSA pada luka dan kini memerlukan penukaran pembalut. PPE manakah yang sesuai?

  1. ATiada PPE, jika tangan dibersihkan selepas itu
  2. BRespirator N95 sahaja, kerana MRSA ialah organisma yang rintang
  3. CGaun dan sarung tangan, serta perlindungan mata dan pelitup muka jika percikan mungkin berlaku
  4. DSarung tangan steril sahaja, tanpa gaun atau perlindungan lain
5.Nilai makmal & elektrolitSederhana

A patient had a total gastrectomy. Which long-term therapy is needed to prevent anemia?

  1. ALifelong oral folic acid tablets only
  2. BMonthly transfusions of red blood cells
  3. CWeekly doses of oral vitamin K tablets
  4. DLifelong vitamin B12 replacement
6.Nilai makmal & elektrolitSukar

At the start of a shift, the nurse reviews four new results. Which patient needs attention first?

  1. AHemoglobin 11.0 g/dL (110 g/L) in a patient with rheumatoid arthritis
  2. BGlucose 180 mg/dL (10 mmol/L) after a meal in a patient with diabetes
  3. CPotassium 5.2 mEq/L in a patient with stable chronic kidney disease
  4. DSodium 119 mEq/L in a patient with new confusion and vomiting
7.Kejururawatan klinikalSederhana

Which finding with a groin hernia needs urgent surgical review?

  1. AThe lump has been present for several years without pain
  2. BThe lump disappears completely when the patient lies down flat
  3. CThe lump gets bigger when the patient coughs
  4. DThe lump has become painful and tender and cannot be pushed back
8.Kejururawatan klinikalSukar

A patient who speaks little English needs to give consent for a procedure. Their 14-year-old child offers to interpret. What is the best action?

  1. AArrange a professional interpreter
  2. BAsk the patient to sign the form without explanation
  3. CLet the child interpret to save time
  4. DUse gestures and proceed
9.Perubatan-pembedahan: kardiovaskular & respiratoriSederhana

Which finding shows that long-standing hypertension has caused target organ damage?

  1. AA heart rate of 72/min
  2. BA normal fasting glucose
  3. CClear lung fields on the chest X-ray
  4. DLeft ventricular hypertrophy on the ECG
10.Perubatan-pembedahan: kardiovaskular & respiratoriSukar

A patient taking warfarin for AF falls and hits their head. An hour later they are drowsy and have vomited. What is the priority?

  1. AEncourage sleep and check observations at the next routine time
  2. BUrgent escalation for CT of the head and anticoagulant reversal
  3. CWithhold tonight's warfarin and review tomorrow
  4. DGive paracetamol (acetaminophen) and a light meal
11.Perubatan-pembedahan: neurologi, endokrin & renalSederhana

Why might a patient bleed more from the needle sites straight after haemodialysis?

  1. AHeparin is often used to stop the circuit from clotting
  2. BDialysis removes all the platelets from the blood
  3. CThe fistula has been damaged and must be tied off
  4. DDialysis raises the blood pressure sharply for several hours
12.Perubatan-pembedahan: neurologi, endokrin & renalSukar

The night after hip surgery, an 84-year-old becomes suddenly confused and tries to pull out their IV line. What is the most appropriate first step?

  1. ATell the family that this is the start of dementia
  2. BLook for causes such as low oxygen, pain, retention or infection
  3. CApply wrist restraints to protect the IV line
  4. DAsk for a strong sedative so that the patient can sleep
13.Perubatan-pembedahan: GI, perioperatif & onkologiSederhana

How should pancreatic enzyme replacement capsules usually be taken?

  1. AOne hour after meals, on an empty stomach
  2. BOnly on days with abdominal pain
  3. COnce a day at bedtime
  4. DWith every meal and snack
14.Perubatan-pembedahan: GI, perioperatif & onkologiSukar

A surgical patient's MUST score is 3 and the wound is healing slowly. What is the most appropriate action?

  1. AEncourage fasting to reduce wound exudate and the size of the dressing
  2. BRepeat the score in three months' time
  3. CRestrict protein to help the kidneys
  4. DRefer to the dietitian, start a nutrition plan and monitor intake

3Larutan

1.Pemberian keutamaan & delegasi

Jawapan: D · Do not measure blood pressure on the left arm

Mengapa ini jawapannya

Blood pressure cuffs, tight bands and heavy loads can damage or block a fistula. The arm with the access is protected, and the nurse checks it for a thrill and bruit.

Jawapan

D · Do not measure blood pressure on the left arm
2.Pemberian keutamaan & delegasi

Jawapan: A · Adrenal crisis from steroid withdrawal

Mengapa ini jawapannya

Patients on long-term steroids may not make enough cortisol to cope with surgical stress. Refractory hypotension suggests adrenal crisis, which needs urgent IV hydrocortisone as prescribed.

Jawapan

A · Adrenal crisis from steroid withdrawal
3.Kawalan jangkitan & keselamatan pesakit

Jawapan: C · Turn the patient on their side and protect them from injury without restraining

Mengapa ini jawapannya

The nurse stays with the patient, turns them to the side to keep the airway clear, moves hard objects away and times the seizure. Objects in the mouth and restraint can cause injury.

Jawapan

C · Turn the patient on their side and protect them from injury without restraining
4.Kawalan jangkitan & keselamatan pesakit

Jawapan: C · Gaun dan sarung tangan, serta perlindungan mata dan pelitup muka jika percikan mungkin berlaku

Mengapa ini jawapannya

MRSA merebak melalui sentuhan, jadi gaun dan sarung tangan dipakai. Langkah berjaga-jaga standard menambah perlindungan mata dan muka apabila percikan cecair luka mungkin berlaku. Respirator tidak diperlukan bagi MRSA pada luka.

Jawapan

C · Gaun dan sarung tangan, serta perlindungan mata dan pelitup muka jika percikan mungkin berlaku
5.Nilai makmal & elektrolit

Jawapan: D · Lifelong vitamin B12 replacement

Mengapa ini jawapannya

Intrinsic factor from the stomach is needed to absorb vitamin B12 in the ileum. After a total gastrectomy, B12 must be replaced for life, usually by injection, to prevent macrocytic anemia and nerve damage.Disemak dengan: Vitamin B12 or folate deficiency anaemia - Causes · NHS (2023); Vitamin B12 deficiency anemia · MedlinePlus (NIH) (2026)

Jawapan

D · Lifelong vitamin B12 replacement
6.Nilai makmal & elektrolit

Jawapan: D · Sodium 119 mEq/L in a patient with new confusion and vomiting

Mengapa ini jawapannya

Severe hyponatremia with confusion and vomiting suggests cerebral edema and can progress to seizures and coma. The other results are mildly abnormal and expected for those conditions, so they are less urgent.Disemak dengan: Low blood sodium - Medical Encyclopedia · MedlinePlus (NIH) (2025); Sodium Blood Test · MedlinePlus (NIH) (2024)

Jawapan

D · Sodium 119 mEq/L in a patient with new confusion and vomiting
7.Kejururawatan klinikal

Jawapan: D · The lump has become painful and tender and cannot be pushed back

Mengapa ini jawapannya

An irreducible, painful, tender hernia, especially with vomiting, suggests incarceration or strangulation. This is a surgical emergency because the trapped bowel can become ischaemic.

Jawapan

D · The lump has become painful and tender and cannot be pushed back
8.Kejururawatan klinikal

Jawapan: A · Arrange a professional interpreter

Mengapa ini jawapannya

Professional interpreters provide accurate, impartial translation and protect confidentiality. Children and family members should not be used for important clinical discussions such as consent.

Jawapan

A · Arrange a professional interpreter
9.Perubatan-pembedahan: kardiovaskular & respiratori

Jawapan: D · Left ventricular hypertrophy on the ECG

Mengapa ini jawapannya

Target organ damage from hypertension includes left ventricular hypertrophy, retinopathy, chronic kidney disease with proteinuria, and stroke. Its presence changes treatment urgency and targets.

Jawapan

D · Left ventricular hypertrophy on the ECG
10.Perubatan-pembedahan: kardiovaskular & respiratori

Jawapan: B · Urgent escalation for CT of the head and anticoagulant reversal

Mengapa ini jawapannya

Head injury in an anticoagulated patient with drowsiness or vomiting suggests intracranial haemorrhage. Urgent CT, neurological observations, an INR and rapid reversal (for warfarin, prothrombin complex concentrate and IV vitamin K) are needed.

Jawapan

B · Urgent escalation for CT of the head and anticoagulant reversal
11.Perubatan-pembedahan: neurologi, endokrin & renal

Jawapan: A · Heparin is often used to stop the circuit from clotting

Mengapa ini jawapannya

Heparin is commonly used during haemodialysis to prevent clotting in the circuit. Its effect can cause prolonged bleeding from puncture sites, so procedures such as IM injections may be timed with care.

Jawapan

A · Heparin is often used to stop the circuit from clotting
12.Perubatan-pembedahan: neurologi, endokrin & renal

Jawapan: B · Look for causes such as low oxygen, pain, retention or infection

Mengapa ini jawapannya

Acute confusion after surgery is often delirium. The nurse first looks for causes: hypoxia, pain, retention, constipation, infection, low glucose, dehydration and drugs. Sedation and restraints can make it worse and are a last resort.

Jawapan

B · Look for causes such as low oxygen, pain, retention or infection
13.Perubatan-pembedahan: GI, perioperatif & onkologi

Jawapan: D · With every meal and snack

Mengapa ini jawapannya

Pancreatic enzymes digest fat, protein and carbohydrate, so they are taken with meals and snacks. The dose is adjusted to reduce steatorrhoea and support weight gain.

Jawapan

D · With every meal and snack
14.Perubatan-pembedahan: GI, perioperatif & onkologi

Jawapan: D · Refer to the dietitian, start a nutrition plan and monitor intake

Mengapa ini jawapannya

A MUST score of 2 or more indicates high risk of malnutrition. Poor nutrition delays healing, so the nurse refers to the dietitian, starts a care plan with food charts and supplements as advised, and rescreens regularly.

Jawapan

D · Refer to the dietitian, start a nutrition plan and monitor intake

Ini ialah bahan latihan bebas. ExamProblems tidak berafiliasi dengan atau disokong oleh organisasi yang mengendalikan peperiksaan ini, dan nama peperiksaan hanya digunakan untuk menerangkan kandungannya. NCLEX®, NCLEX-RN® and NCLEX-PN® ialah tanda dagangan the National Council of State Boards of Nursing, Inc. (NCSBN), yang tidak bergabung dengan ExamProblems, tidak menyokongnya dan tidak menjamin ketepatannya.

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