Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Two hours after birth, the nurse finds the uterus firm but above the umbilicus and pushed to the right. What should the nurse do first?

1. AMassage the uterus firmly for ten minutes
2. BHelp the patient empty her bladder
3. CGive a dose of oxytocin straight away
4. DAsk the patient to lie still for another hour

Two call lights go on at the same time. One patient has pain of 7/10 after surgery. The other is a confused patient at high risk of falls who is climbing out of bed alone. Who does the nurse go to first?

1. AThe confused patient climbing out of bed
2. BThe patient in pain after surgery
3. CThe patient whose call light went on first
4. DWhichever patient’s room is closer to the station

A nurse’s hands are dry and cracked from frequent hand hygiene. What is the best approach?

1. AWear gloves all day instead of cleaning the hands between patients
2. BUse any lotion from home, whatever its contents
3. CStop hand hygiene until the skin heals
4. DUse the hand lotion approved by the facility to keep the skin intact

Which patient with a suspected infection meets at least two SIRS criteria?

1. ATemperature 37.2 °C and heart rate 80/min
2. BTemperature 38.6 °C and heart rate 112/min
3. CRespiratory rate 16/min and WBC 8,000/mm³
4. DTemperature 36.8 °C and respiratory rate 18/min

A woman who is 30 weeks pregnant has a new blood pressure of 152/98 mm Hg. Which urine finding would most support preeclampsia?

1. AProtein in the urine
2. BGlucose in the urine
3. CNitrites in the urine
4. DKetones in the urine

Weeks after neck surgery, a patient has muscle cramps and tingling. Calcium is low, phosphate is high and parathyroid hormone (PTH) is low. Which condition fits best?

1. AHypoparathyroidism
2. BChronic kidney disease
3. CVitamin D toxicity
4. DPrimary hyperparathyroidism

What should a patient be told before using sublingual glyceryl trinitrate (GTN, nitroglycerin) spray for angina?

1. ASit down before using it, as it can cause dizziness and low blood pressure
2. BSwallow the spray rather than leaving it under the tongue
3. CTake it with a large glass of milk to protect the stomach lining
4. DUse it only after the pain has lasted over an hour, with the patient lying flat

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. ARefeeding syndrome
2. BSyndrome of inappropriate ADH secretion
3. CAdrenal insufficiency
4. DTumour lysis syndrome

A patient has a heart rate of 36/min with hypotension and dizziness. Which drug is usually the first choice?

1. AOral bisoprolol
2. BIntravenous adenosine
3. CIntravenous amiodarone
4. DIntravenous atropine

A patient's blood gas shows pH 7.26, PaCO₂ 9.0 kPa (68 mmHg) and bicarbonate 25 mmol/L. What does this show?

1. ARespiratory alkalosis
2. BAcute respiratory acidosis
3. CMetabolic alkalosis
4. DMetabolic acidosis with compensation

Which group of drugs is a well-known cause of SIADH and hyponatraemia, especially in older people?

1. ABulk-forming laxatives
2. BPenicillin antibiotics
3. CProton pump inhibitors
4. DSSRI antidepressants

A patient with a head injury now has a blood pressure of 190/70 mmHg, a pulse of 48/min and irregular breathing. How should the nurse interpret this?

1. AHypovolaemic shock from internal bleeding
2. BCushing's triad, a late sign of raised intracranial pressure
3. CNeurogenic shock from a spinal cord injury
4. DA normal stress response to pain, anxiety and the noise of the ward

Sebesar manakah bukaan perkakas stoma patut dipotong?

1. ASedikit lebih kecil daripada stoma untuk kedapan yang ketat
2. BSebarang saiz, asalkan stoma tertutup
3. CKira-kira 2–3 mm lebih besar daripada stoma di sekelilingnya
4. DKira-kira 2 cm lebih besar daripada stoma di sekelilingnya

A competent adult who is a Jehovah's Witness refuses blood transfusion before major surgery. What should the nurse do?

1. AAsk the family to override the decision
2. BPlan to transfuse secretly during the operation if it becomes needed
3. CCancel the surgery without discussing it
4. DRespect the decision, document it and inform the team