Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Before accessing a central venous catheter, what should the nurse do to prevent infection?

1. AScrub the hub with an antiseptic such as chlorhexidine and let it dry
2. BBlow on the hub to remove any dust before connecting the syringe or line
3. CRinse the hub with tap water and dry it
4. DTouch the hub to check it is clean

Seorang pesakit dengan kecederaan kepala dan patah kaki sedang dipantau. Dapatan manakah yang menjadi keutamaan?

1. APesakit meminta sesuatu untuk dimakan
2. BKesakitan kaki 6/10 walaupun dos analgesia terakhir
3. CSkor Skala Koma Glasgow jatuh daripada 15 kepada 12
4. DLecet kecil pada siku

A colleague has drawn up a medication and asks the nurse to give it to her patient. What should the nurse do?

1. AGive it, and document that the colleague prepared it
2. BDecline, and give only medications that the nurse prepared or checked personally
3. CGive it, because the colleague is experienced
4. DGive it, as long as the syringe has a label with the drug name on it

A nurse teaches a patient going home with an MRSA wound infection. Which statement shows a need for further teaching?

1. A“I will wash my hands after touching my dressing.”
2. B“I can share towels with my family if I wash them every week.”
3. C“I will keep the wound covered with a clean, dry dressing.”
4. D“I will put used dressings in a sealed bag before throwing them out.”

Hemoglobin seorang pesakit ialah 7.8 g/dL (78 g/L). Dapatan manakah yang dijangka oleh jururawat?

1. AKadar denyutan jantung perlahan, kulit kemerahan dan tekanan darah tinggi
2. BSakit kepala, mimisan dan muka merah
3. CKeletihan, pucat, kadar denyutan jantung yang laju dan sesak nafas apabila bergerak
4. DGatal, kulit kuning dan air kencing gelap

A patient with chronic kidney disease stage 4 has a high phosphate, a low-normal calcium and a very high parathyroid hormone (PTH). What does this show?

1. AVitamin D toxicity from supplements
2. BHypoparathyroidism after neck surgery
3. CSecondary hyperparathyroidism from CKD
4. DPrimary hyperparathyroidism from a tumor

Why are patients asked to fast before a general anaesthetic?

1. ATo lower the blood glucose before surgery
2. BTo prevent postoperative constipation and abdominal bloating
3. CTo make the surgery shorter
4. DTo reduce the risk of aspirating stomach contents

A patient with severe ulcerative colitis develops abdominal distension, fever and tachycardia, and the number of stools falls. What complication should be suspected?

1. ACoeliac disease
2. BToxic megacolon
3. CConstipation from dehydration
4. DRecovery from the colitis

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. CWalking only on days when the legs feel warm and painless
4. DComplete bed rest until the leg pain has gone for at least a month

A patient has sudden severe chest pain spreading to the back between the shoulder blades. Which finding most supports aortic dissection rather than myocardial infarction?

1. APain that started at rest
2. BA heart rate of 104/min and a respiratory rate of 22/min
3. CA large difference in blood pressure between the arms
4. DSweating, nausea and pallor that started with the pain

Which complication is a particular risk in nephrotic syndrome?

1. ABleeding from low platelets
2. BLow cholesterol
3. CVenous thrombosis
4. DHypoglycaemia

Selepas pembedahan, seorang pesakit penyakit Graves mempunyai suhu 39.8 °C, kadar jantung 160/min, kegelisahan dan muntah. Set rawatan manakah yang paling sesuai?

1. ASekatan cecair dan diuretik gelung untuk merawat takikardia
2. BLevotiroksin dan selimut hangat untuk menenangkan menggigil
3. CPenyejukan, penyekat beta, ubat antitiroid, kemudian iodin dan steroid
4. DAspirin untuk demam dan semakan oleh GP dalam seminggu

Which early symptoms suggest local anaesthetic systemic toxicity?

1. AA red rash only at the injection site, with no other symptoms
2. BIncreased hunger and thirst over several hours, with a dry mouth
3. CMild itching of the feet the next day
4. DTingling around the mouth, a metallic taste and tinnitus

Just after extubation in recovery, a patient develops a high-pitched noise on breathing in, with falling SpO₂. What should the nurse do first?

1. AGive an opioid to calm the patient's breathing and reduce anxiety
2. BCall for help, give 100% oxygen and use a jaw thrust
3. CWait a few minutes to see if it passes
4. DSit the patient up and give a drink of water