Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

On day 3 after hip surgery, a patient suddenly becomes short of breath with sharp chest pain and an SpO₂ of 88%. What should the nurse do first?

1. ARaise the head of the bed, give oxygen and call for urgent help
2. BEncourage the patient to walk to improve the circulation
3. CMassage the patient’s calves to ease any muscle cramp
4. DGive the next dose of oral analgesia and reassess the patient in an hour

Which patient is the most appropriate to assign to an LPN/LVN?

1. AA patient who has just arrived from the emergency department with pneumonia and confusion
2. BA patient on a new IV medication that needs frequent titration
3. CA patient with a long-standing tracheostomy who needs routine suctioning and care
4. DA patient with a tracheostomy placed this morning who is coughing up blood

A patient has a very low platelet count. Which safety measure is appropriate?

1. AUse a soft toothbrush and an electric razor
2. BUse a firm toothbrush and a safety razor
3. CTake rectal temperatures for accuracy
4. DFloss hard each day to keep the gums healthy

A patient in a vest restraint has slid down in bed, and the vest is pressing against the neck. What should the nurse do first?

1. ATighten the vest so the patient cannot slide down again
2. BWrite a note about the event in the chart
3. CCall the provider to ask about a different restraint
4. DRelease the restraint at once and reposition the patient

During a red cell transfusion, when are serious acute reactions most likely, so the nurse stays with the patient?

1. AAfter the last drop is given
2. BThe next morning
3. CIn the first 15 minutes
4. DAfter about 2 hours

A patient has a continuous heparin infusion for a pulmonary embolism. A new nurse plans to adjust the infusion using today's INR of 1.1. What should the experienced nurse explain?

1. AThe INR is the correct test, and 1.1 means heparin is therapeutic
2. BThe INR of 1.1 means the heparin rate must be doubled at once
3. CHeparin is adjusted using the aPTT or anti-Xa level, not the INR
4. DHeparin needs no laboratory monitoring once the infusion is started

Which advice is important for a patient on long-term oral corticosteroids?

1. ATake them on an empty stomach at night
2. BDo not stop them suddenly
3. CTake them only when symptoms flare
4. DDouble the dose if a dose is missed

Penemuan manakah yang paling kuat mencadangkan embolisme pulmonari pada pesakit pascaoperasi?

1. ABerdehit yang bertambah baik dengan salbutamol
2. BPermulaan batuk beransur-ansur dengan kahak kuning dan demam ringan selama seminggu
3. CKadar jantung perlahan dengan tekanan darah tinggi
4. DSesak nafas mendadak dan sakit dada pleuritik dengan takikardia

Mengapakah nitrat digunakan dengan sangat berhati-hati dalam infarksi ventrikel kanan?

1. AVentrikel kanan bergantung pada prabeban, jadi tekanan darah boleh jatuh mendadak
2. BNitrat tidak diserap apabila ventrikel kanan terjejas
3. CNitrat menyebabkan hiperkalemia yang berbahaya dalam jenis infarksi ini
4. DNitrat menyebabkan infarksi merebak ke ventrikel kiri

A patient with crushing chest pain has ST elevation in leads V1–V4. Which coronary artery is most likely blocked?

1. AThe right coronary artery and its branches
2. BThe circumflex artery
3. CThe left subclavian artery
4. DThe left anterior descending artery

For which patient would the nurse question an order for pioglitazone?

1. AA patient with asthma
2. BA patient with heart failure
3. CA patient with hypothyroidism
4. DA patient with an allergy to latex

Semasa infusi alteplas untuk strok, pesakit mengalami sakit kepala teruk, muntah dan GCS yang menurun. Apakah yang patut dilakukan oleh jururawat dahulu?

1. AMempercepatkan infusi supaya ia tamat lebih awal
2. BMemberikan sedatif untuk menenangkan pesakit dan meneruskan
3. CMemberikan antiemetik dan menyemak semula GCS dalam sejam
4. DMenghentikan infusi dan memanggil pasukan strok dengan segera

Why should metoclopramide not be used for nausea in mechanical bowel obstruction?

1. AIt makes the bowel stop moving completely
2. BIt increases gut movement against the blockage
3. CIt blocks the effect of all opioids
4. DIt always causes severe diarrhoea

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. CRefer to the dietitian, start a nutrition plan and monitor intake
4. DRestrict protein to help the kidneys