Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Which patient should the RN see first after receiving a report from the night nurse?

1. ADay 2 after bowel surgery, asking to start a soft diet
2. BDay 1 after bowel surgery, new chest pain and heart rate 110/min
3. CDay 3 after bowel surgery, wants a shower and hair wash before breakfast
4. DDay 4 after bowel surgery, waiting for discharge teaching

After a cervical spinal cord injury, a patient has a blood pressure of 80/50 mmHg, a heart rate of 48/min and warm, dry skin. What is most likely?

1. ACardiac tamponade
2. BNeurogenic shock
3. CSeptic shock
4. DHypovolemic shock

Mengapakah ubat cecair oral diberikan dengan picagari oral atau enteral dan bukannya picagari IV piawai?

1. APicagari oral menyukat dos intravena dengan lebih tepat
2. BTiada sebab keselamatan; ia hanya tradisi
3. CPicagari oral tidak muat pada talian IV, mencegah kesilapan laluan yang salah
4. DPicagari IV tidak dapat menyukat isi padu kecil cecair oral dengan tepat

Only one airborne infection isolation room (negative pressure) is free. Which newly admitted patient should be placed in it?

1. AA patient with C. difficile diarrhea
2. BA patient with suspected active pulmonary tuberculosis
3. CA patient with an MRSA wound infection
4. DA patient with confirmed seasonal influenza and a cough

Which finding during a transfusion suggests transfusion-associated circulatory overload (TACO)?

1. AHives and itching without other signs
2. BCrackles, hypertension and a raised BNP
3. CA low temperature and slow heart rate
4. DBack pain with dark red urine output

An RN cares for a patient on a 24-hour urine collection. Which task can be delegated to unlicensed assistive personnel (UAP), such as a nursing or healthcare assistant?

1. AInterpreting the creatinine clearance result when it comes back
2. BSaving all urine in the collection container as instructed
3. CDeciding whether to restart the collection after a missed sample
4. DTeaching the patient why the 24-hour collection is needed

What should a patient starting oral iron tablets be told?

1. ATheir urine will turn bright green
2. BTheir stools may turn dark or black
3. CThey must take the tablets with strong tea
4. DThe tablets will cause weight loss

A patient has a single hot, swollen, very painful knee and a fever. Why is urgent joint aspiration important?

1. ATo prevent osteoporosis
2. BTo measure the patient's cholesterol
3. CTo rule out septic arthritis, which can rapidly destroy the joint
4. DTo check for rheumatoid arthritis antibodies in the joint fluid

After coronary artery bypass surgery through a median sternotomy, which instruction is usually given for the first several weeks?

1. AAvoid heavy lifting and pushing up with the arms
2. BSleep only on the stomach to protect the wound
3. CLift the arms above the head often to stretch the chest
4. DAvoid walking until the stitches are removed

A patient with severe sepsis becomes increasingly breathless over 24 hours. SpO₂ stays low despite high-flow oxygen, and the chest X-ray shows bilateral infiltrates. The heart function is normal. Which condition is most likely?

1. ASpontaneous pneumothorax
2. BAn acute asthma attack
3. CAcute respiratory distress syndrome
4. DAcute left ventricular failure after an MI

A bladder scan straight after voiding shows 450 mL of urine still in the bladder. What does this show?

1. AThe patient has drunk too little fluid
2. BThe kidneys are making too little urine
3. CThe patient is passing urine normally
4. DThe bladder is not emptying properly

A patient with SIADH needs IV fluid. Which fluid is most likely to worsen the hyponatraemia?

1. A20% human albumin
2. B3% saline
3. C8.4% sodium bicarbonate
4. D5% glucose (dextrose, D5W)

Masalah elektrolit manakah yang boleh berlaku dalam pankreatitis akut yang teruk?

1. AHiperkalsemia
2. BHiperkalemia
3. CHipernatremia
4. DHipokalsemia

On day 5 after a major burn, a patient is confused, with a temperature of 39.2 °C, tachycardia, and an offensive, discoloured wound. What should the nurse suspect?

1. ADelirium from boredom on the ward
2. BBurn wound infection with sepsis
3. CAn allergy to the dressing only
4. DThe normal hypermetabolic response alone