Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A nasogastric tube has just been placed for feeding. What must happen before the first feed is given?

1. AThe feed is started slowly to see if the patient coughs
2. BThe tube is flushed with a large volume of water
3. CPlacement is confirmed by an approved method
4. DThe patient is asked if the tube feels comfortable

On an addiction unit, which patient should the nurse assess first?

1. ADrowsy with pinpoint pupils and a respiratory rate of 7/min
2. BYawning, with a runny nose and dilated pupils
3. CAnxious, with goose bumps, stomach cramps and loose stools
4. DAsking for an extra blanket and a hot drink

Before helping a patient from bed into a wheelchair, what should the nurse do with the wheelchair?

1. ALock the brakes and place it close to the bed on the patient’s stronger side
2. BPlace it on the patient’s weaker side so that side is supported
3. CPlace it at the foot of the bed, facing away
4. DLeave the brakes off so the chair can move along with the patient during the pivot

During a power cut in a US hospital, a ventilator must stay powered. Where should it be plugged in?

1. AInto an extension cord from the corridor
2. BInto any white outlet in the room
3. CInto the outlet that is closest to the bed, whatever its color
4. DInto a red outlet connected to the emergency generator

The heparin infusion rate was changed according to protocol. When is the aPTT usually rechecked?

1. AOnly after the infusion is stopped
2. BAbout 30 minutes after the change
3. CAbout 6 hours after the change
4. DAbout 3 days after the change

A child with sickle cell disease and a recent viral illness is pale and tired. The hemoglobin has fallen sharply, and the reticulocyte count is very low. What is the most likely problem?

1. AA normal finding in sickle cell disease
2. BIron deficiency from a poor diet over months
3. CA vaso-occlusive pain crisis in the bones
4. DAn aplastic crisis, often caused by parvovirus B19

Which features suggest pyelonephritis rather than simple cystitis?

1. ACloudy urine with no other symptoms
2. BFrequency without any pain
3. CMild burning on passing urine only
4. DFever, rigors and loin pain

A patient who speaks little English needs to give consent for a procedure. Their 14-year-old child offers to interpret. What is the best action?

1. AArrange a professional interpreter
2. BUse gestures and proceed
3. CAsk the patient to sign the form without explanation
4. DLet the child interpret to save time

Which energy-conservation advice is most useful for a patient with severe COPD?

1. ADo all the household tasks quickly in the morning to get them done
2. BHold the breath while lifting heavy objects
3. CAvoid any activity at all, staying in a chair to save their energy
4. DSit down for tasks such as washing and dressing, and pace activities

A 74-year-old with atrial fibrillation, hypertension and diabetes asks why she needs an anticoagulant when she feels well. Which reply is best?

1. AThe anticoagulant will stop the irregular heartbeat for good
2. BIt is needed only while she has palpitations
3. CIt is given to lower her blood pressure
4. DHer risk of stroke is high, and an anticoagulant lowers it

Which picture fits Brown-Séquard syndrome?

1. AWeakness of both arms with normal strength in the legs
2. BParalysis of both legs, with normal sensation everywhere in the body
3. CLoss of all feeling but normal movement on both sides
4. DWeakness on the same side and loss of pain on the opposite side

On day 6 after a subarachnoid haemorrhage, a patient becomes newly confused and develops weakness in one arm. The aneurysm was secured on day 1. What is the most likely cause?

1. AHypoglycaemia from reduced eating
2. BDelayed cerebral ischaemia from vasospasm
3. CNormal tiredness after major surgery
4. DRe-bleeding from the secured aneurysm

How should a patient with facial burns usually be positioned?

1. ALying face down on the pillow to protect the airway
2. BIn any position that keeps the face covered
3. CLying flat with the head lower than the feet
4. DWith the head of the bed raised to reduce swelling

A patient with gallstones has a temperature of 39 °C with rigors, jaundice and right upper abdominal pain. What should the nurse suspect?

1. AAcute hepatitis A
2. BSimple biliary colic
3. CUncomplicated reflux
4. DAscending cholangitis