Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Seorang pesakit dewasa yang sedang makan di bilik harian tiba-tiba mencekik lehernya dan tidak boleh bercakap, bernafas atau batuk. Apakah yang patut dilakukan oleh jururawat dahulu?

1. ABeri pesakit segelas air untuk menolak makanan turun
2. BMinta bantuan dan beri tepukan belakang dan tujahan abdomen
3. CLakukan sapuan jari secara buta dalam mulut
4. DTunggu untuk melihat sama ada pesakit boleh terbatuk keluar

Seorang jururawat menganggap dos yang ditetapkan tidak selamat. Pemreskripsi menyuruh memberikannya juga. Apakah yang patut dilakukan oleh jururawat?

1. ATahan dos dan eskalasi melalui rantaian pemerintahan
2. BBeri dos itu, kerana pemreskripsi kini bertanggungjawab atasnya
3. CLangkau dos secara senyap dan tidak berkata apa-apa untuk mengelakkan konflik
4. DBeri separuh dos sebagai kompromi dan dokumenkan sebabnya

Hair must be removed from a planned surgical site. Which method reduces the risk of surgical site infection?

1. AClipping with electric clippers just before surgery
2. BUsing wax strips on the morning of surgery
3. CShaving with a razor just before the incision
4. DShaving with a disposable razor the night before surgery

A patient punches a nurse during care. The nurse is not seriously hurt. What should the nurse do?

1. APunch the patient back in self-defense
2. BGet medical assessment and report the assault according to policy
3. CRefuse to care for any patient for the rest of the week until the patient is moved
4. DSay nothing, because violence is part of the job

A patient with hyperkalemia is prescribed an oral potassium binder such as patiromer or sodium zirconium cyclosilicate. How does this drug lower potassium?

1. AIt protects the heart muscle against high potassium levels
2. BIt binds potassium in the gut so it leaves in the stool
3. CIt stops the kidneys from absorbing water in the tubules
4. DIt moves potassium into cells in the next few minutes

Three days after starting haloperidol, a patient has a temperature of 40 °C, severe muscle rigidity and confusion. Which laboratory result would the nurse expect?

1. AA very high creatine kinase (CK)
2. BA very low white cell count
3. CA very low serum sodium
4. DA very high serum lithium

Pemerhatian manakah yang paling penting selepas memberi pesakit dos pertama antibiotik baharu secara intravena?

1. ASama ada keguguran rambutnya bertambah
2. BBerapa banyak dia berjalan pada hari itu
3. CTanda tindak balas alahan seperti ruam, berdehit atau bengkak
4. DSeleranya pada hidangan seterusnya

After a head injury, a patient has clear fluid leaking from the nose. What does this most likely suggest?

1. AAllergic rhinitis triggered by the hospital environment
2. BA base-of-skull fracture with a cerebrospinal fluid leak
3. CAcute sinusitis
4. DA normal and harmless response to head trauma

Cecair dalam saluran dada telah berhenti berayun. Apakah maksudnya?

1. APneumotoraks baharu telah terbentuk di sebelah yang lain
2. BUnit saliran telah mula menyalirkan abdomen
3. CParu-paru telah mengembang semula, atau tiub berlipat atau tersumbat
4. DParas air dalam ruang kini terlalu tinggi untuk bergerak

On a ventilated patient, the end-tidal CO₂ waveform suddenly drops to zero. What should the nurse suspect first?

1. ANormal variation that needs no action
2. BA rise in the patient's body temperature over the last hour
3. CA sudden improvement in the patient's lung function
4. DTube displacement, disconnection or obstruction

A patient has taken metformin for many years and now has tingling feet and a low haemoglobin. Which blood test is most relevant?

1. AThyroid antibodies
2. BSerum amylase
3. CVitamin B12 level
4. DBlood alcohol level

Why might a frail 88-year-old with type 2 diabetes have a less strict HbA1c target?

1. ATo reduce the risk of hypos, falls and confusion
2. BBecause diabetes cannot damage older people
3. CTo save money on blood tests and drugs
4. DBecause older people cannot use any glucose medicines

Why is the time a surgical limb tourniquet is inflated carefully recorded?

1. AIt shows how long the anaesthetic gas was used
2. BThe tourniquet slowly loses all its air after one minute
3. CLong inflation can cause nerve and muscle damage
4. DThe surgeon is paid per minute of use

While a central line is disconnected, a patient suddenly becomes breathless with chest pain and hypotension. Air embolism is suspected. What should the nurse do first?

1. ASit the patient fully upright and flush the line
2. BRemove the central line straight away and leave the site open to the air
3. CClamp the line, lie the patient left side down, head low; give oxygen
4. DGive the patient a drink and observe for an hour