Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A patient taking warfarin has an INR of 5.2 and no signs of bleeding. What should the nurse do?

1. AGive a double dose to correct the result
2. BEncourage the patient to take aspirin for pain
3. CGive the usual dose and recheck the INR next month
4. DHold the warfarin dose and inform the provider

A patient with suspected sepsis has four prescribed orders. Which should usually be done first?

1. ATake blood cultures
2. BArrange a chest X-ray for later today
3. CGive the IV antibiotic
4. DRepeat the lactate in six hours

A patient with a fentanyl skin patch wants to use a heating pad on the area. What should the nurse teach?

1. AHeat makes the patch last longer, so fewer patches are needed each month
2. BHeat is fine to use, because it helps the patch stick better to the skin
3. CAvoid heat on or near the patch, because it increases how fast the drug is absorbed
4. DHeat only matters if the patch is on the chest

A patient refuses to wear an identification wristband. What should the nurse do?

1. AStop giving the patient any care until they agree to wear the band
2. BAccept the refusal and identify the patient by room number and bed space instead
3. CExplain why it is needed, use other ID methods per policy and document
4. DForce the band onto the patient’s wrist

A tired patient with heavy menstrual periods has a normal hemoglobin and MCV but a ferritin of 8 ng/mL. What does this show?

1. AVitamin B₁₂ deficiency anemia
2. BA completely normal iron status
3. CIron overload from too much iron
4. DIron deficiency without anemia yet

A patient's total calcium is 7.6 mg/dL and the albumin is 2.0 g/dL. Using the common correction (add 0.8 mg/dL for each 1 g/dL that albumin is below 4.0), what is the corrected calcium?

1. A11.6 mg/dL, above the normal range
2. B7.6 mg/dL, below the normal range
3. C6.0 mg/dL, well below the normal range
4. D9.2 mg/dL, within the normal range

Which equipment must always be kept at the bedside of a patient with a tracheostomy?

1. AA blood glucose meter and a spare urinary catheter of the same size
2. BA blood pressure cuff and a spare nasal cannula and oxygen mask only
3. CSpare tracheostomy tubes, including one a size smaller, and working suction
4. DA peak flow meter and a nebuliser

Soon after starting chemotherapy for a high-grade lymphoma, a patient has rising potassium, phosphate and uric acid with falling urine output. What is the most likely cause?

1. ATumour lysis syndrome
2. BRefeeding syndrome
3. CAdrenal insufficiency
4. DSyndrome of inappropriate ADH secretion

Which emergency equipment should be kept at the bedside of a patient with a tracheostomy?

1. AA urinary catheter set, a blood glucose meter and a thermometer
2. BA nasogastric tube and a feeding pump
3. COnly a spare oxygen mask, since the tube rarely causes problems
4. DSpare tubes (same size and one smaller), suction and oxygen

The monitor of a patient with a permanent pacemaker shows pacing spikes, but none of them is followed by a QRS complex. What does this mean?

1. AFailure to sense
2. BFailure to capture
3. CAtrial fibrillation
4. DNormal pacemaker function

A patient has Cushing's syndrome. Which nursing assessment is especially important?

1. AChecking for low blood pressure
2. BWatching for weight loss
3. CRegular blood glucose checks
4. DMonitoring for a high potassium

A kidney transplant recipient has had vomiting and diarrhoea for two days. Why should the transplant team be contacted?

1. AThe patient may not be absorbing their immunosuppressants
2. BVomiting proves that rejection has already happened
3. CThe kidney will start to produce far too much urine
4. DThe tablets will make the vomiting stop

Which statement about fatigue during radiotherapy is correct?

1. AIt means the radiotherapy has failed
2. BIt often builds during the course and can last for weeks
3. CIt occurs only after the first session and then disappears completely
4. DIt is caused by the patient becoming radioactive

Seorang pesakit dengan lecuran 35% TBSA memasuki fasa hipermetabolik. Pelan pemakanan manakah yang paling sesuai?

1. ADiet rendah protein untuk melindungi buah pinggang daripada kerosakan
2. BBerpuasa selama dua minggu untuk merehatkan usus sepenuhnya
3. CCecair jernih sahaja sehingga luka lecuran sembuh
4. DPemakanan enteral awal, tinggi tenaga dan protein