Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A nasogastric tube has just been placed for feeding. What must happen before the first feed is given?

1. AThe patient is asked if the tube feels comfortable
2. BThe tube is flushed with a large volume of water
3. CThe feed is started slowly to see if the patient coughs
4. DPlacement is confirmed by an approved method

Seorang pembantu jururawat mengukur tanda vital 15 minit selepas dos pertama morfin pesakit. Mereka melaporkan kadar pernafasan 10/min dan berkata pesakit sukar dikejutkan. Apakah yang patut dilakukan oleh jururawat?

1. APergi serta-merta, kejutkan pesakit, sokong pernafasan dan sediakan nalokson mengikut arahan
2. BMendokumenkan dapatan dan memberitahu pembekal penjagaan pada pusingan berjadual seterusnya
3. CMeminta pembantu memeriksa semula kadar pernafasan dalam 15 minit dan melapor semula
4. DMenelefon pembekal penjagaan untuk arahan sebelum pergi melihat pesakit

Setegang manakah sekatan pergelangan tangan patut dipasang?

1. ACukup longgar untuk memuatkan dua jari di antara sekatan dan kulit
2. BCukup ketat untuk memperlahankan nadi di pergelangan tangan
3. CCukup longgar untuk tangan pesakit tergelincir keluar
4. DSeketat yang mungkin supaya pesakit tidak boleh menggerakkan lengan

A nurse has a needlestick from a patient whose HIV and hepatitis status is unknown. What should happen?

1. ANothing, because the source patient is probably not infected
2. BThe nurse is assumed to be infected and stops all work
3. CThe source patient is tested per policy, and the nurse has baseline tests
4. DThe nurse waits six months before having any blood tests at all

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

Set keputusan manakah yang paling tipikal bagi anemia kekurangan zat besi?

1. AHemoglobin tinggi dan hematokrit tinggi
2. BHemoglobin normal dengan kiraan platelet yang tinggi sahaja
3. CHemoglobin rendah, sel darah merah besar (MCV tinggi) dan feritin tinggi
4. DHemoglobin rendah, sel darah merah kecil (MCV rendah) dan feritin rendah

A patient with pneumonia is breathless and coughing up thick sputum. Which nursing measure helps most with breathing?

1. ARestricting all oral fluids
2. BDiscouraging coughing to save energy
3. CLying the patient flat so that they can rest and conserve energy
4. DSitting the patient upright and supporting them to clear secretions

During a blood transfusion, an older patient with heart failure becomes breathless with a rising blood pressure, raised JVP and crackles in the lungs. What is the most likely cause?

1. ATransfusion-associated circulatory overload
2. BA febrile non-haemolytic reaction
3. CAnaphylaxis
4. DTransfusion-related acute lung injury with hypotension

After varicose vein surgery, which advice is usually given?

1. AWear the compression stockings as advised and walk regularly
2. BStand still for long periods to help the veins heal
3. CAvoid all walking until the bruising has gone
4. DStay in bed for two weeks with the legs hanging down

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. AHypovolaemic shock from bleeding
2. BEarly septic (distributive) shock
3. CCardiogenic shock
4. DObstructive shock from tamponade

Why are insulin and glucose given together to treat hyperkalaemia?

1. AInsulin protects the heart muscle cells from the potassium
2. BInsulin moves potassium into cells; glucose prevents a hypo
3. CGlucose binds the potassium in the blood and removes it
4. DInsulin makes the kidneys pass more potassium in the urine

Penjagaan kejururawatan manakah yang penting bagi pesakit yang menerima manitol untuk tekanan intrakranial yang meningkat?

1. AMenghentikan carta imbangan cecair semasa rawatan
2. BMengapit kateter untuk mengekalkan cecair dalam badan
3. CPemantauan rapi pengeluaran air kencing, natrium dan osmolaliti
4. DMemberikan ubat secara oral bersama makanan untuk mengurangkan loya

Which statement about moist wound healing is correct?

1. AWounds should be soaked in water for hours every day
2. BA moist, not wet, wound bed helps cells move and heal faster
3. CA wet wound bed always prevents infection
4. DWounds heal fastest when left to dry out and form a scab

A category (stage) 4 pressure ulcer is now healing and shallower. How should it be documented according to standard guidance?

1. AAs a category 2 pressure ulcer now
2. BAs a healing category 4 pressure ulcer
3. CAs a category 1 pressure ulcer now
4. DAs a fully healed ulcer that can be removed from the record