Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

During labor, the nurse sees the umbilical cord in the vagina after the membranes rupture. What is the first action?

1. APush the cord back into the uterus
2. BWait for the next contraction before acting
3. CRelieve pressure on the cord by lifting the presenting part with a gloved hand
4. DAsk the patient to walk around the room to bring the baby lower and speed up labor

A child is admitted with a suspected Wilms tumor (nephroblastoma). Which instruction is most important for all staff?

1. AMeasure abdominal girth by pressing firmly
2. BDo not palpate the abdomen
3. CEncourage the child to play contact sports
4. DGive a warm bath with abdominal massage

Which measure reduces errors caused by interruptions during medication preparation?

1. AAnswering phone calls and pages while counting tablets, to save time
2. BA quiet “no interruption” zone or signal while preparing medications
3. CPreparing medications at the busiest place on the ward
4. DPreparing medications for all patients at once

A nurse teaches a patient about home oxygen safety. Which statement shows a need for further teaching?

1. A“I can light candles at dinner if my oxygen is turned down low.”
2. B“I will put a ‘no smoking’ sign on my front door for visitors.”
3. C“I will keep my oxygen away from the stove.”
4. D“I will keep my spare cylinders upright and secured.”

A patient with hyponatremia from SIADH starts tolvaptan. Why is the serum sodium checked frequently in the first day?

1. AThe drug lowers blood glucose sharply
2. BThe sodium always falls further
3. CThe drug causes severe hyperkalemia
4. DThe sodium can rise too quickly

The nurse teaches a patient with severe neutropenia after chemotherapy. Which statement shows a need for further teaching?

1. A"I'll check my temperature rectally to be accurate"
2. B"I'll wash my hands before eating and after the toilet"
3. C"I'll avoid people who have a cold or the flu"
4. D"I'll call the clinic if my temperature rises"

Why are patients asked to fast before a general anaesthetic?

1. ATo make the surgery shorter
2. BTo reduce the risk of aspirating stomach contents
3. CTo lower the blood glucose before surgery
4. DTo prevent postoperative constipation and abdominal bloating

A nurse teaches a patient with heart failure about self-care. Which statement shows a need for further teaching?

1. A"I will take my water tablet in the morning."
2. B"I will report it if I need more pillows to sleep."
3. C"I will weigh myself each morning after passing urine."
4. D"I only need to weigh myself once a month."

How should a patient breathe in when using a dry powder inhaler?

1. AQuickly and deeply, after breathing out away from the device
2. BThrough the nose with the mouthpiece in the mouth
3. CSeveral times, breathing out into the device between breaths
4. DSlowly and gently over about ten seconds

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

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

Mengapakah kalium mesti dipantau dengan teliti apabila insulin IV diberikan untuk DKA?

1. AInsulin menyebabkan buah pinggang mengekalkan kalium, jadi aras akan meningkat
2. BInsulin tidak mempunyai kesan terhadap kalium dalam DKA
3. CInsulin memindahkan kalium ke dalam sel, jadi aras boleh jatuh dengan cepat
4. DInsulin memecahkan kalium dalam aliran darah

A patient on carbamazepine is admitted confused, with a sodium of 121 mmol/L. Which explanation is most likely?

1. AConfusion is a normal, expected effect of carbamazepine and is unrelated to sodium
2. BCarbamazepine can cause hyponatraemia through an SIADH-like effect
3. CCarbamazepine causes salt loss through severe diarrhoea
4. DThe low sodium proves the patient has stopped taking the drug

Tanda manakah yang menunjukkan pankreatitis akut yang teruk dengan pendarahan ke dalam tisu?

1. ALebam di sekeliling pusat atau rusuk
2. BRuam ungu pada tapak tangan dan kaki
3. CBengkak pada bibir, lidah dan muka
4. DPerubahan warna kuning pada kuku jari

A nurse teaches a carer about overnight tube feeding at home. Which statement shows a need for further teaching?

1. A"I'll stop the feed and call if he coughs or struggles to breathe."
2. B"I'll let him lie flat so he sleeps better while the feed runs."
3. C"I'll check the external length mark on the tube every day."
4. D"I'll flush the tube with water before and after his medicines."