Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Which action by a nursing assistant needs the nurse to step in?

1. APutting the call light within the patient’s reach
2. BLowering the bed to its lowest position and locking the wheels after care
3. CCleaning hands before entering the room
4. DTaking an oral temperature just after the patient drank cold water

Four patients arrive at the emergency department at the same time. Who should be seen first?

1. AAn older adult with weakness on one side that began 40 minutes ago
2. BAn adult with kidney stone pain of 9/10 and stable vital signs
3. CA child with a temperature of 39 °C who is alert and drinking
4. DA young adult with a swollen, painful ankle after a fall on the stairs

Bilakah langkah berjaga-jaga titisan bagi pesakit dengan Neisseria meningitidis lazimnya dihentikan?

1. ASelepas 24 jam rawatan antibiotik yang berkesan
2. BSelepas demam hilang selama satu jam
3. CHanya selepas pesakit discaj
4. DSebaik sahaja dos antibiotik pertama diberikan

During a procedure, a nurse sees that the team is about to start without a time-out. What should the nurse do?

1. AWait and raise the issue after the procedure is finished
2. BSpeak up clearly and stop the start until the time-out is done
3. CReport it to the manager at the end of the week
4. DSay nothing, because the surgeon is responsible for the procedure

A patient on warfarin has an INR of 7.8 and a nosebleed. Which medication would the nurse expect the provider to prescribe?

1. ANaloxone hydrochloride
2. BProtamine sulfate
3. CAcetylcysteine
4. DVitamin K (phytonadione)

A patient on lithium has had vomiting and diarrhea for 3 days and has been taking ibuprofen. They now have a coarse tremor and confusion. The lithium level is 2.2 mEq/L. What is the best interpretation and action?

1. AA normal level; continue lithium as prescribed
2. BIbuprofen side effects only; give it with food
3. CLithium toxicity; hold lithium and report urgently
4. DA low level; ask for the lithium dose to be raised

A dying patient can no longer drink and has a dry mouth. What is the most appropriate nursing care?

1. AFrequent mouth care that keeps the lips and mouth moist
2. BInserting a nasogastric tube for fluids
3. CLeaving the mouth alone to avoid disturbing them
4. DStarting a fast intravenous infusion to correct the dryness

Why can pulse oximetry be misleading in carbon monoxide poisoning?

1. AThe oximeter overheats in smoke-exposed patients
2. BStandard oximeters cannot tell carboxyhaemoglobin from oxyhaemoglobin
3. CCarbon monoxide only affects the heart rate reading
4. DCarbon monoxide makes the oximeter read zero even in a well patient

After an acute coronary syndrome, a patient with a normal cholesterol level is prescribed a high-intensity statin. Why?

1. AStatins reduce further events whatever the starting cholesterol
2. BStatins work as painkillers for chest pain
3. CStatins are given after an ACS mainly to lower the blood pressure
4. DStatins are needed only if the cholesterol level is very high

Thirty minutes after extubation, a patient develops a high-pitched noise on breathing in and is anxious. SpO₂ is falling. What should the nurse do?

1. AGive a large drink of cold water to soothe the throat and settle it
2. BLay the patient flat and reassure them
3. CEncourage the patient to sleep it off and recheck them in an hour
4. DSit the patient up, give oxygen and call for urgent airway help

A patient's potassium stays low despite replacement. Which other level should be checked?

1. AMagnesium
2. BFerritin
3. CBilirubin
4. DAmylase

Seorang pesakit diabetes insipidus kranial memulakan desmopresin. Komplikasi manakah yang patut dipantau oleh jururawat?

1. AHiponatremia
2. BHiperkalemia
3. CHiperglisemia
4. DCirit-birit teruk

What is achalasia?

1. AFailure of the lower oesophageal sphincter to relax on swallowing
2. BInflammation of the oesophagus caused by a fungal infection
3. CA tear at the junction of the oesophagus and the stomach
4. DWeakness of the lower oesophageal sphincter that allows reflux

A nurse teaches a patient about a fentanyl skin patch. Which statement shows a need for further teaching?

1. A"I won't put a hot water bottle over the patch."
2. B"I'll fold used patches sticky sides together before disposal."
3. C"I can cut the patch in half if I need less."
4. D"I'll put the new patch on a different area of skin."