Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Seorang dewasa yang stabil dengan tanda vital normal mempunyai luka pada tangan yang memerlukan jahitan dan tiada yang lain. ESI tahap manakah yang sesuai?

1. ATahap 2
2. BTahap 4
3. CTahap 5
4. DTahap 3

Laporan pembantu jururawat manakah yang patut ditindaki dahulu oleh jururawat?

1. APesakit pneumonia telah batuk kahak kuning
2. BPesakit yang berehat di katil meminta pan katil
3. CPesakit diabetes berkata kakinya sering terasa kebas-kebas, seperti kebiasaannya
4. DSelepas pelakuran tulang belakang lumbar pagi ini, tidak dapat merasa atau menggerakkan kaki

How should a nurse handle soiled bed linen?

1. APut it on the floor until the bed is made
2. BHold it away from the uniform and place it straight into a linen bag
3. CCarry it bundled against the body to the soiled utility room down the hall
4. DShake it out first to check for lost items

A patient on contact precautions for MRSA has become withdrawn and says, “Everyone avoids me.” What is the best nursing action?

1. AStop the precautions for a few days so the patient feels less isolated and alone
2. BKeep visits short to limit the risk of spreading MRSA
3. CAsk the provider for a sedative to help the patient cope
4. DExplain why the precautions are needed and plan regular, unhurried time in the room

Sebelum memberi kalium klorida IV yang ditetapkan, penilaian manakah yang paling penting?

1. ATurgor kulit pada lengan bawah
2. BPendengaran di kedua-dua telinga
3. CKeluaran air kencing dan fungsi buah pinggang
4. DSaiz anak mata dan tindak balas terhadap cahaya

A patient with thalassemia major has received regular red cell transfusions for years. The ferritin is now very high. What does this most likely show, and what treatment is used?

1. AIron overload, treated with iron chelation therapy
2. BAcute infection, treated with broad-spectrum antibiotics
3. CLiver failure, treated with a liver transplant at once
4. DIron deficiency, treated with IV iron supplements

Why is an ankle–brachial pressure index (ABPI) measured before applying compression bandages to a leg ulcer?

1. ATo work out the patient's fluid needs
2. BTo measure how deep the ulcer is and how much exudate it produces
3. CTo exclude significant arterial disease, as compression could cut off blood flow
4. DTo check for a urinary tract infection that could delay ulcer healing

A nurse realises she has given a patient a medicine prescribed for another patient. What should she do first?

1. AAsk a colleague not to mention it
2. BWait to see whether any side effects develop
3. CCheck the patient's condition and inform the doctor
4. DGive the patient's own medicine as well to balance it

A woman had lymph nodes removed from her left armpit for breast cancer. Which advice helps reduce the risk of lymphoedema?

1. AKeep the left arm hanging down and as still as possible all day
2. BUse only the left arm for heavy lifting to build up its muscles
3. CApply tight jewellery to the left wrist
4. DAvoid BP cuffs and injections on the left arm where possible

A patient with asthma needs their reliever every three hours and their peak flow is falling well below their personal best. What does their action plan most likely advise?

1. AWait two weeks to see whether it improves without any change
2. BFollow the worsening-asthma steps and get a same-day review
3. CDo extra exercise to open the airways
4. DStop the preventer inhaler for a few days to rest the lungs

A patient with myasthenia gravis wants to plan a busy day. Which advice fits the disease?

1. AAvoid rest periods, because rest makes the weakness worse
2. BDo demanding tasks in the morning or when the drug works best
3. CDo the hardest tasks in the evening when muscles are warmed up
4. DExercise to exhaustion so the muscles get stronger quickly

A patient with diabetes insipidus after head trauma needs hourly urine output measurement. Which task can be delegated to a trained healthcare assistant (nursing assistant)?

1. AInterpreting the serum sodium results
2. BMeasuring hourly urine and reporting results above a set amount
3. CDeciding whether to give the next desmopressin dose
4. DAssessing the patient's level of consciousness

A patient on warfarin is booked for elective surgery with a high bleeding risk. What is usual practice?

1. ADouble the dose for a week so the blood is ready for surgery
2. BTake the usual dose on the morning of surgery
3. CStop it about 5 days before and check the INR
4. DSwap to aspirin on the morning of surgery

Which preoperative task can a registered nurse usually delegate to a healthcare assistant (nursing assistant)?

1. ADeciding whether abnormal results need reporting
2. BRecording baseline vital signs
3. CTeaching the patient how to use a PCA pump
4. DAssessing the patient's understanding of the surgery