Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A drowsy patient who has just returned from surgery starts to vomit. What should the nurse do first?

1. AGive a drink of water
2. BRaise the legs above the heart
3. CTurn the patient onto their side
4. DGive an oral anti-sickness tablet

Seorang pesakit kegagalan jantung sesak nafas dengan krepitasi di kedua-dua paru-paru. Tertib tindakan manakah yang betul?

1. ABeri ubat oral berjadual dahulu, kemudian dudukkan pesakit tegak
2. BBaringkan pesakit rata untuk berehat, kemudian mulakan cecair penyelenggaraan IV
3. CTimbang pesakit dahulu, kemudian nilai semula pernafasan dalam empat jam
4. DDuduk tegak, beri oksigen seperti yang ditetapkan, kemudian hubungi pembekal penjagaan

A patient has patient-controlled analgesia (PCA). A family member presses the button while the patient sleeps. What should the nurse explain?

1. AThe pump will always stop any overdose
2. BOnly the patient should press it, because this keeps the system safe
3. CPressing it while the patient sleeps prevents the pain from getting worse later
4. DFamily can press it as long as they count the presses

A nurse cannot find a confused patient who was in their room 15 minutes ago. What should the nurse do first?

1. ADocument the absence at the end of the shift
2. BWait an hour in case the patient comes back
3. CAlert staff and security at once, following the missing-patient procedure
4. DCall the family to ask whether the patient has gone home on their own

A patient has a calcium of 11.8 mg/dL (2.95 mmol/L) from bone metastases. Which nursing measure is appropriate?

1. AEncourage fluids and mobility as tolerated
2. BGive calcium carbonate antacids for nausea
3. CEncourage bed rest and limit oral fluids
4. DOffer extra milk and cheese at each meal

Two sets of blood cultures were taken from separate sites. Only one bottle in one set grows coagulase-negative staphylococci, and the patient has no line or implant. What is the most likely interpretation?

1. ACertain bloodstream infection needing treatment
2. BProof that the patient has infective endocarditis
3. CInfection with a resistant organism such as MRSA
4. DProbable skin contamination of the sample

A rising serum creatinine most often indicates:

1. ADehydration of the skin only
2. BImproved liver function
3. CIncreased muscle strength
4. DReduced kidney function

Which action is most important in protecting a patient with severe neutropenia from infection?

1. ATaking rectal temperatures regularly
2. BKeeping fresh flowers and plants in the room to help the patient's mood
3. CGiving routine intramuscular injections
4. DStrict hand hygiene by everyone who has contact with the patient

Seorang pesakit sakit dada meminta gliseril trinitrat. Maklumat manakah bermakna jururawat patut menahannya dan menghubungi pempreskripsi?

1. APesakit mengambil statin setiap hari
2. BTekanan darah pesakit ialah 150/90 mmHg
3. CPesakit mengambil sildenafil awal hari ini
4. DPesakit mengalami sakit kepala minggu lepas

A patient with a valid, documented do-not-attempt-CPR decision (DNACPR in the UK, DNR or DNAR in the US) is found in cardiac arrest. What should the nurse do?

1. AStart CPR but use only chest compressions
2. BNot start CPR, call for support, and provide dignity and comfort
3. CCall the arrest team and let them decide whether to resuscitate
4. DStart full CPR because the patient's family is not present

Seorang pesakit mengalami hemianopia homonim selepas strok. Bagaimanakah jururawat patut membantu pada mulanya?

1. AMenutup mata di sebelah yang terjejas dengan tampalan
2. BMeletakkan loceng panggilan dan minuman di sebelah yang tiada penglihatan, untuk melatihnya
3. CMemastikan bilik gelap untuk mengurangkan rangsangan visual
4. DMendekati dari sebelah yang boleh melihat dan mengajar memalingkan kepala untuk mengimbas

A patient arrives five hours after the onset of a stroke. A CT angiogram shows a blockage of a large artery in the brain. What is the most appropriate next step?

1. AStart IV alteplase immediately without further imaging
2. BGive aspirin and plan a review on the ward tomorrow
3. CUrgent referral for assessment for mechanical thrombectomy
4. DNo treatment, because the time for any reperfusion has passed

Penilaian di sisi katil manakah yang digunakan untuk mengikuti asites?

1. AAliran puncak dan ketepuan oksigen
2. BBerat harian dan lilitan abdomen
3. CSaiz anak mata dan tindak balas dua kali sehari
4. DGlukosa kapilari sebelum setiap hidangan

A colleague suggests giving a saline injection to see whether a patient's pain is "real". What is the best response?

1. AIt is a good idea, as long as the patient is not told about it afterwards
2. BIt should be done only for patients with chronic pain
3. CIt is acceptable if a senior nurse gives the saline
4. DDeceptive placebos are unethical and do not show pain is "fake"