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. AGive a dose of oxytocin straight away
2. BMassage the uterus firmly for ten minutes
3. CHelp the patient empty her bladder
4. DAsk the patient to lie still for another hour

Using ESI, a stable adult with abdominal pain will need blood tests and a CT scan, but has a heart rate of 130/min. Which statement is correct?

1. AThe patient is level 4 because the blood tests and the scan count as one resource
2. BThe nurse should consider level 2 because of the danger-zone vital sign
3. CVital signs never change the ESI level
4. DThe patient is level 5 because the pain is not severe

Seorang jururawat mengalami kecederaan tertusuk jarum daripada pesakit yang diketahui menghidap HIV. Mengapakah penting untuk melaporkannya dengan segera?

1. AProfilaksis pasca-pendedahan paling berkesan jika dimulakan dalam masa beberapa jam
2. BPelaporan hanya diperlukan jika luka berdarah atau dalam
3. CPelaporan boleh dibuat pada bila-bila masa dalam sebulan tanpa mengubah risiko
4. DPelaporan hanya diperlukan bagi kecederaan daripada jarum IV

A nurse has a needlestick from a patient with hepatitis B. The nurse finished the vaccine series and has a documented protective antibody level. Which statement is correct?

1. AThe nurse must stop all patient care for six months
2. BNo hepatitis B treatment is needed, but the injury is still reported and followed up
3. CNo reporting is needed because the nurse is immune
4. DHepatitis B immune globulin and a complete new vaccine series are both needed at once

A patient with type 1 diabetes has the flu, is eating little and has a glucose of 290 mg/dL (16.1 mmol/L). Which advice is correct?

1. AStop all insulin until you are eating normally again
2. BWait 3 days before checking the glucose again
3. CDrink only water and avoid all carbohydrate foods
4. DKeep taking insulin and check blood or urine ketones

A patient with a stable INR on warfarin starts rifampin (rifampicin) for tuberculosis. Two weeks later the INR is 1.3. What is the most likely explanation?

1. ATuberculosis causes the INR to fall
2. BRifampin contains a lot of vitamin K
3. CRifampin speeds up warfarin metabolism
4. DRifampin raises the INR, so it is wrong

Which drug is first-line in an acute asthma attack?

1. AA long-acting inhaled corticosteroid, used alone at a higher dose
2. BAn oral beta-blocker
3. CA nebulised or inhaled short-acting beta₂-agonist (salbutamol/albuterol)
4. DAn oral antihistamine such as cetirizine taken every few hours

A nurse realises she has given a patient a medicine prescribed for another patient. What should she do first?

1. AGive the patient's own medicine as well to balance it
2. BWait to see whether any side effects develop
3. CCheck the patient's condition and inform the doctor
4. DAsk a colleague not to mention it

Which position is usually best for the legs of a patient with chronic venous insufficiency and ankle swelling?

1. AHanging down over the side of the bed
2. BCrossed at the knees while sitting
3. CKept still in a standing position for long periods
4. DRaised above the level of the heart when resting

During a thrombolytic infusion for an MI, the patient develops a sudden severe headache, vomiting and new confusion. What should the nurse do first?

1. AContinue the infusion, as headache is a common side effect
2. BStop the infusion and call for urgent medical help
3. CSlow the infusion and give an antiemetic
4. DGive a second dose to finish the treatment

After a lumbar discectomy, which finding should the nurse report promptly?

1. AMild pain at the wound site
2. BStiffness when getting out of bed
3. CA dry, intact wound dressing
4. DNew weakness or numbness in the legs

The nurse has four patients with diabetes. Which one needs to be seen first?

1. AA newly diagnosed patient asking about which foods to eat
2. BA patient with a glucose of 14 mmol/L (252 mg/dL) who feels well and is eating
3. CA patient with a glucose of 2.8 mmol/L (50 mg/dL) who is sweaty and confused
4. DA patient waiting for a routine HbA1c test

When breaking bad news, what is the first step in frameworks such as SPIKES?

1. AGive all treatment options before checking understanding
2. BSet up a private setting with enough time
3. CAsk the family to decide what the patient should be told
4. DGive the diagnosis as quickly as possible in the corridor

A patient with haematemesis becomes drowsy and starts to vomit blood again. What is the immediate priority?

1. ATurn the patient onto their side to protect the airway
2. BComplete the admission paperwork and medication history
3. CSend a stool sample for faecal occult blood testing
4. DGive a large glass of iced water to slow the bleeding