Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A nurse teaches a patient who uses home oxygen. Which statement shows a need for further teaching?

1. A“I will keep the oxygen away from the gas stove.”
2. B“I will put up no-smoking signs at the front door and in my room.”
3. C“My husband can smoke in my room if the window is open.”
4. D“I will not use oil-based creams on my face.”

A patient with raised intracranial pressure is being nursed on the ward. Which position is best?

1. AHead down with the legs raised above the heart
2. BFlat on the back with the head turned well over to one side
3. CSitting forward with the chin on the chest
4. DHead of the bed at about 30 degrees with the neck straight

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. BTurn the patient on their side and protect them from injury without restraining
3. CGive sips of water to keep the airway moist
4. DHold the arms and legs firmly to stop the movements

Victims of a chemical spill arrive at the emergency department with liquid on their skin and clothing. What is the priority before they enter the building?

1. ATake a full history in the waiting room
2. BGive them hospital gowns and seat them in triage
3. CTake them straight into the resuscitation room so treatment is not delayed
4. DDecontaminate them outside, with staff wearing appropriate PPE

A healthy patient has a mildly raised CK after running a marathon yesterday, without dark urine or symptoms. What is the most likely explanation?

1. AThe patient has developed acute hepatitis
2. BStrenuous exercise raised CK from skeletal muscle
3. CThe patient has developed acute pancreatitis
4. DAn acute myocardial infarction has occurred

A frail older adult in a nursing home has been drinking very little during a heat wave. She is confused, and her sodium is 158 mEq/L. Which treatment would the nurse expect?

1. AStrict fluid restriction to below 800 mL a day
2. BA loop diuretic to remove the extra sodium quickly
3. CRapid infusion of 3% saline to raise the volume
4. DGradual replacement of free water over many hours

Why are patients advised to rinse their mouth after using an inhaled corticosteroid?

1. ATo reduce the risk of oral thrush
2. BTo make the drug work faster
3. CTo prevent tooth decay from the sugar in it
4. DTo stop the drug from being absorbed in the lungs

A drowsy patient in recovery is making snoring sounds and the SpO₂ is falling. What is the first action?

1. ALie the patient face down
2. BWait for the patient to wake up fully
3. CGive sips of oral fluid to clear the throat and wake them
4. DOpen the airway with a head tilt–chin lift or jaw thrust

Which exercise advice is recommended for intermittent claudication?

1. ASupervised walking until pain is near maximal, then rest and repeat
2. BStopping walking at the very first twinge of pain each time
3. CComplete bed rest until the leg pain has gone for at least a month
4. DWalking only on days when the legs feel warm and painless

A nurse is reviewing four telemetry patients. Which rhythm needs attention first?

1. ASinus bradycardia of 54/min in a patient who is asleep and comfortable
2. BRate-controlled atrial fibrillation at 82/min
3. CRepeated runs of ventricular tachycardia in a patient who feels dizzy
4. DFirst-degree heart block with a stable blood pressure and no symptoms

A patient takes an SGLT2 inhibitor. Which sick-day advice is correct?

1. APause the drug during illness with vomiting or poor intake
2. BKeep taking it as normal, whatever the illness
3. CStop drinking fluids while taking the drug
4. DDouble the dose during illness to control the glucose

Seorang pesakit dalam vest halo untuk patah tulang belakang servikal mengalami henti jantung. Apakah yang mesti tersedia dengan segera?

1. AGunting untuk memotong pin tengkorak
2. BPapan keras untuk diselitkan di bawah vest
3. CAlat untuk membuka bahagian hadapan vest bagi CPR
4. DBantal untuk menaikkan kepala dan bahu

A patient has taken oral prednisolone daily for many months. Why is this important before surgery?

1. AThey may need extra steroid cover to prevent an adrenal crisis
2. BSteroids prevent all wound infections after surgery
3. CSteroids make the anaesthetic drugs last much longer
4. DSteroids must always be stopped a full week before any type of surgery

After two days of large volumes of IV 5% glucose, a postoperative patient becomes confused with a headache. Sodium is 124 mmol/L. What is the likely cause?

1. AHyponatraemia from hypotonic fluids
2. BHypoglycaemia from the glucose
3. CNormal confusion after any anaesthetic
4. DHypernatraemia from too much salt