Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A patient receiving IV magnesium sulfate for pre-eclampsia has absent knee reflexes and a respiratory rate of 10/min. What does the nurse do first?

1. AStop the magnesium infusion and call for help
2. BIncrease the infusion to prevent a seizure
3. CTurn the patient onto her back and recheck later
4. DGive oral fluids to help clear the drug faster

A patient taking an SSRI is also given tramadol. A few hours later the patient is agitated, sweating and has a fever, jerking muscles and brisk reflexes. What is the most likely cause?

1. ASerotonin syndrome
2. BAn anxiety attack
3. COpioid withdrawal
4. DNeuroleptic malignant syndrome

A parent says, “I tell my son his medicine is candy so he takes it.” What should the nurse teach?

1. AThis is a good idea and makes giving medicine easier
2. BDo not call medicine candy, because the child may take it when no one is watching
3. CIt is fine as long as the medicine is kept in the fridge
4. DIt only matters for medicines that taste bitter or are hard to swallow

During a disaster, the hospital needs to free beds quickly. Which patient is the best candidate for early discharge?

1. AA patient admitted overnight for observation who is now stable with normal tests
2. BA patient on a ventilator in the intensive care unit who is slowly improving
3. CA patient with ongoing chest pain awaiting cardiac tests
4. DA patient on an IV heparin infusion that is still being adjusted

Seorang pesakit mempunyai natrium 152 mEq/L. Dapatan manakah yang dijangka oleh jururawat?

1. APertambahan berat badan dengan buku lali bengkak
2. BBradikardia dengan gelombang T runcing
3. CKedutan otot dengan tanda Trousseau yang positif
4. DDahaga, membran mukus kering dan kegelisahan

An RN cares for a patient on a 24-hour urine collection. Which task can be delegated to unlicensed assistive personnel (UAP), such as a nursing or healthcare assistant?

1. ASaving all urine in the collection container as instructed
2. BTeaching the patient why the 24-hour collection is needed
3. CInterpreting the creatinine clearance result when it comes back
4. DDeciding whether to restart the collection after a missed sample

A patient has a continuous stream of bubbles in the water seal chamber of their chest drain. What does this most likely indicate?

1. AAn air leak, from the lung or from the drainage system
2. BThe drain is working normally for a fluid collection only
3. CThe drain is blocked
4. DThe lung has fully re-expanded

In a patient with a head injury, which is usually the earliest sign of rising intracranial pressure?

1. AIrregular breathing pauses
2. BA slow pulse with high blood pressure
3. CA fixed, dilated pupil on both sides
4. DA change in level of consciousness

What is the purpose of a mucolytic such as carbocisteine in chronic productive cough?

1. ATo stop the patient coughing completely, day and night
2. BTo kill bacteria in the airways
3. CTo widen the airways within minutes
4. DTo make sputum thinner and easier to cough up

Seorang pesakit yang mengambil warfarin untuk fibrilasi atrium mempunyai INR 8.5 tetapi tiada pendarahan. Apakah pengurusan yang paling mungkin?

1. AMemberikan konsentrat kompleks protrombin dan pemindahan darah
2. BMeneruskan dos biasa dan menyemak semula INR dalam sebulan
3. CMenahan warfarin, memaklumkan pempreskripsi dan menyemak semula INR tidak lama lagi
4. DMemberikan protamin sulfat IV serta-merta untuk menterbalikkannya

How does bladder training help urge incontinence?

1. AThe time between voids is slowly increased
2. BThe patient goes to the toilet every 15 minutes
3. CA catheter is used every night
4. DThe patient drinks as little as possible

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

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

Seorang pesakit pendarahan GI atas akut mempunyai hemoglobin normal semasa tiba. Mengapakah ini boleh mengelirukan?

1. AIa jatuh hanya selepas anjakan cecair atau cecair IV mencairkan darah
2. BHemoglobin hanya jatuh selepas seminggu pendarahan berterusan
3. CHemoglobin sentiasa meningkat pada mulanya selepas sebarang kehilangan darah
4. DHemoglobin tidak terjejas oleh pendarahan daripada usus

A patient's ileostomy output is 2.5 L a day. They feel tired and dizzy and are drinking large amounts of water. Which advice is usually appropriate?

1. AEat only fruit and fruit juice
2. BDrink even more plain water and tea to replace the losses
3. CStop all drinking for 24 hours
4. DLimit plain drinks and use an oral rehydration solution