Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Which SBAR recommendation is the clearest?

1. A“I would like you to see him within 15 minutes and consider a fluid bolus.”
2. B“He seems a bit off tonight, so maybe you could come up and do something about it.”
3. C“I will keep watching him and call again tomorrow.”
4. D“I just wanted to let you know about him.”

A patient who is 7 weeks pregnant has one-sided lower abdominal pain, pain in the shoulder tip, a heart rate of 120/min and a blood pressure of 88/54 mmHg. What is most likely?

1. AA normal early pregnancy
2. BSevere morning sickness
3. CA urinary tract infection
4. DA ruptured ectopic pregnancy

Sebelum mengakses hab kateter vena pusat, apakah yang patut dilakukan oleh jururawat?

1. AMengelapnya dengan pantas menggunakan kasa steril kering
2. BTiada apa-apa, kerana hab dilindungi di bawah penutup steril
3. CMenyental hab dengan antiseptik dan membiarkannya kering
4. DMeniup hab perlahan-lahan untuk membuang habuk

A patient takes medicines prescribed by several providers. Which advice best reduces the risk of medication errors at home?

1. AOnly tell each provider about the drugs they prescribed
2. BKeep each provider’s medicines in separate bags
3. CKeep one up-to-date list of all medicines and use one pharmacy where possible
4. DStop taking any medicine that seems to repeat another one, without asking anyone

Perubahan ECG manakah yang dikaitkan dengan hipokalsemia?

1. ASela QT yang memanjang
2. BGelombang delta yang menonjol
3. CGelombang T yang tinggi dan runcing
4. DSela QT yang memendek

Semasa infusi magnesium sulfat IV, penilaian manakah yang paling baik mengesan ketoksikan lebih awal?

1. ABunyi usus dan lilitan abdomen
2. BGlukosa darah dan saiz anak mata setiap jam
3. CWarna kulit dan pengisian semula kapilari setiap jam
4. DRefleks lutut, kadar pernafasan dan keluaran air kencing

A patient has lost more than 10% of their body weight without trying over the last few months and has a low BMI. What is the most appropriate action?

1. ARestrict fluids to encourage appetite and give a low-protein diet instead
2. BRefer to the dietitian and start a nutrition care plan with food charts
3. CWeigh the patient again in six months and review at that point
4. DEncourage a low-calorie diet

A patient with a small leg wound has severe pain out of proportion to the skin changes, rapidly spreading redness and signs of sepsis. What should be suspected?

1. AAn allergic reaction to the dressing
2. BA superficial bruise
3. CNecrotising fasciitis
4. DSimple cellulitis that will settle with oral antibiotics

A patient's blood pressure is high in clinic but normal on home readings. Which step best confirms the diagnosis?

1. AA single repeat reading in the same clinic visit
2. BAmbulatory or structured home blood pressure monitoring
3. CA chest X-ray
4. DStarting two antihypertensive drugs at once at full dose

A patient declines enoxaparin for VTE prevention because it is made from pork, which conflicts with their beliefs. What is the best response?

1. ATell the patient that refusal means they cannot have surgery
2. BRespect the decision, inform the prescriber and discuss non-animal options
3. CDocument the refusal in the notes and take no further action at all
4. DGive the injection anyway without explaining what the medicine is made from

Why is good blood pressure control important in chronic kidney disease?

1. AIt raises the haemoglobin level in the blood
2. BIt slows the decline in kidney function
3. CIt lowers the blood glucose
4. DIt cures chronic kidney disease

A patient received IV insulin and glucose for hyperkalaemia an hour ago. What must the nurse monitor over the next few hours?

1. ACapillary glucose, for hypoglycaemia
2. BPupils, for raised intracranial pressure
3. CSkin, for a drug rash
4. DUrine colour, for blood in the urine

After a spinal anaesthetic, which nursing check is particularly important?

1. APupil reaction every five minutes for the next full day
2. BBlood glucose every 15 minutes overnight
3. CReturn of leg sensation and movement, and passing urine
4. DPeak flow before and after each meal

A patient has sharp, tearing pain on passing stool, "like passing glass", with a streak of fresh blood. Which condition is most likely?

1. AAnal fissure
2. BColorectal cancer
3. CUpper GI bleeding
4. DCrohn's disease of the ileum