Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Which newborn finding needs prompt reporting?

1. ABluish hands and feet in the first hours
2. BJaundice that appears within the first 24 hours
3. CMilia (small white spots) on the nose
4. DMild jaundice that first appears on the third day

A patient with a head injury has a pupil on one side that is now large and does not react to light. What should the nurse do?

1. ARecheck it at the next routine observation in four hours
2. BDocument it, because pupils often differ slightly after a head injury
3. CReport it at once, as it may mean the brain is being compressed
4. DDim the room lights so the pupil can get smaller

A patient with delirium is at risk of falls and of pulling out lines. Which option is less restrictive than restraints?

1. AA trained sitter or video monitoring with staff nearby
2. BFour side rails raised and the door closed so the patient stays in bed
3. CA sedative given every few hours as needed
4. DA vest restraint applied for the whole night

A nurse teaches an older adult about preventing falls at home. Which statement shows a need for further teaching?

1. A“I keep small rugs in the hall so my feet stay warm.”
2. B“I wear shoes with non-slip soles around the house.”
3. C“I had grab bars put in next to the toilet.”
4. D“I use night lights between my bedroom and the bathroom.”

Mengapakah pesakit dengan kegagalan hati boleh mempunyai INR yang meningkat tanpa mengambil warfarin?

1. AHati menghasilkan kebanyakan faktor pembekuan, maka pengeluarannya menurun
2. BBilirubin memusnahkan faktor pembekuan secara langsung
3. CAlbumin ialah faktor pembekuan, dan parasnya menurun
4. DBuah pinggang berhenti menyingkirkan faktor pembekuan daripada darah

A patient on high-dose dexamethasone has a white cell count of 15 × 10³/µL, mostly mature neutrophils with no bands. They have no fever and no signs of infection. What is the most likely explanation?

1. AA steroid effect that moves neutrophils into the circulating blood
2. BA laboratory error, because steroids always lower the white count
3. CCertain sepsis that needs antibiotics started without delay
4. DA new leukemia that is confirmed by this result alone

Which advice is correct for a patient taking levothyroxine?

1. AStop taking it once the symptoms improve
2. BTake it only on days when feeling tired
3. CTake it with a large meal to avoid nausea and stomach upset
4. DTake it on an empty stomach, usually before breakfast

A patient has new facial weakness. Which feature suggests a stroke rather than Bell's palsy?

1. AThe forehead can still be wrinkled on the affected side
2. BThe patient has had a recent cold
3. CThe whole of one side of the face, including the forehead, is weak
4. DThe patient has pain behind the ear

A peripheral cannula site is red, warm, tender and swollen along the vein. What should the nurse do?

1. ACover the site and keep using it until it blocks
2. BFlush the cannula hard to clear it
3. CLeave it in place, as this is normal after 24 hours
4. DRemove the cannula, document and monitor the site

A ventilated patient with severe ARDS is to be turned prone. What is the main reason, and the key nursing risk?

1. AIt improves oxygenation; risks are pressure injury and tube displacement
2. BIt improves digestion and gut motility; the main risk is constipation
3. CIt treats infection; the risk is fever
4. DIt lowers the blood pressure; the main risk is rebound hypertension

Kriteria kecederaan buah pinggang akut (KDIGO) manakah yang berkaitan dengan pengeluaran air kencing?

1. ADi bawah 1 L dalam 24 jam tanpa mengira pengambilan
2. BDi bawah 2 mL/kg/j selama 1 jam
3. CDi bawah 0.5 mL/kg/j selama 6 jam atau lebih
4. DSebarang perubahan warna air kencing

A patient with polycystic kidney disease suddenly has the worst headache of their life and neck stiffness. What should the nurse suspect?

1. AA subarachnoid haemorrhage from a brain aneurysm
2. BPain spreading upwards from a kidney cyst
3. CA migraine linked to high blood pressure
4. DA urinary infection that has spread

Which is a recognised cause of anaphylaxis during surgery?

1. AChlorhexidine skin preparation
2. BA warmed blanket
3. CThe patient's own blood from cell salvage
4. DSterile normal saline

A worker has a hydrofluoric acid burn on the hand and severe pain. After irrigation with water, which specific treatment is commonly applied?

1. ASilver sulfadiazine cream
2. BSodium bicarbonate paste
3. CIce cubes wrapped in a cloth
4. DCalcium gluconate gel