Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A patient taking lithium has vomiting, diarrhea and a new coarse tremor. What should the nurse do?

1. AEncourage the patient to cut down on salt and fluids
2. BReassure the patient that a coarse tremor is expected at first
3. CGive the dose with food to reduce the stomach upset
4. DHold the next dose and report for an urgent lithium level

A patient with a severe asthma attack had a PaCO₂ of 32 mmHg (4.3 kPa) on arrival. An hour later it is 46 mmHg (6.1 kPa), and the patient seems tired. What does this suggest?

1. AThe asthma is improving, because the PaCO₂ is now near normal
2. BA laboratory error that should be ignored
3. CThe patient is hyperventilating even more than before and needs calming
4. DRespiratory muscle fatigue with possible impending respiratory failure

A patient with difficulty swallowing is prescribed an extended-release tablet. What should the nurse do?

1. ACut the tablet in half so it is easier to swallow
2. BDissolve the tablet in a glass of hot water
3. CAsk the prescriber or pharmacist for another form and not crush the tablet
4. DCrush the tablet finely and mix it into a spoonful of applesauce or yogurt

Pada pagi pembedahan, pesakit berkata pembedahan itu pada lutut kiri, tetapi borang persetujuan menyatakan lutut kanan. Apakah yang patut dilakukan oleh jururawat?

1. AMengikut pesakit, kerana pesakit paling mengenali badan sendiri
2. BMengikut borang persetujuan, kerana ia telah ditandatangani
3. CMenandakan kedua-dua lutut supaya mana-mana satu boleh dibedah
4. DBerhenti dan memberitahu pakar bedah, supaya tapak disahkan dahulu

A patient on a heparin infusion has an aPTT below the target range on the protocol. What should the nurse do?

1. AContinue the same rate and recheck the aPTT in a few days
2. BSwitch the infusion to oral warfarin without a prescription
3. CAdjust the rate as the protocol directs and recheck as scheduled
4. DStop the infusion and give protamine sulfate as quickly as possible

Dapatan manakah yang paling kuat mencadangkan bahawa kreatinin pesakit yang meningkat disebabkan oleh kecederaan buah pinggang akut dan bukan penyakit buah pinggang kronik yang lama?

1. APesakit mengalami anemia yang lama
2. BPesakit mempunyai buah pinggang yang kecil pada imbasan ultrabunyi
3. CKreatinin normal tiga hari lalu dan telah berganda sejak itu
4. DPesakit telah mempunyai kreatinin tinggi selama bertahun-tahun

Carta imbangan cecair pesakit menunjukkan pengambilan 1,200 mL dan pengeluaran 2,300 mL dalam tempoh 24 jam. Apakah yang ditunjukkan oleh ini?

1. AImbangan cecair negatif sebanyak 1,100 mL
2. BImbangan cecair positif sebanyak 3,500 mL
3. CStatus cecair seimbang
4. DImbangan cecair positif sebanyak 1,100 mL

Penemuan manakah yang paling kuat mencadangkan embolisme pulmonari pada pesakit pascaoperasi?

1. APermulaan batuk beransur-ansur dengan kahak kuning dan demam ringan selama seminggu
2. BKadar jantung perlahan dengan tekanan darah tinggi
3. CBerdehit yang bertambah baik dengan salbutamol
4. DSesak nafas mendadak dan sakit dada pleuritik dengan takikardia

A patient is going home with a 24-hour Holter monitor. Which instruction is most important?

1. AShower as normal with the monitor on
2. BRemove the monitor whenever symptoms occur and restart it
3. CStay in bed for the full 24 hours so the trace is clear
4. DKeep a diary of symptoms and activities with the times

A nurse teaches a patient how to measure blood pressure at home. Which statement shows a need for further teaching?

1. A"I will rest quietly for five minutes before measuring."
2. B"I will measure it straight after my morning jog."
3. C"I will sit with my back supported and my arm at heart level."
4. D"I will take two readings and write them both down."

Which picture fits anterior cord syndrome?

1. ALoss of movement and pain sense, with position sense kept
2. BNormal movement but complete loss of position sense
3. CArms much weaker than legs after a neck injury
4. DWeakness on one side and loss of pain sensation on the other side

Seorang pesakit dengan pemakanan enteral berterusan semalaman menerima insulin yang dijadualkan mengikut suapan. Pada pukul 02:00 tiub tersumbat dan suapan berhenti. Apakah risiko utama, dan apakah yang patut dilakukan oleh jururawat?

1. AKetoasidosis; menghentikan semua insulin sehingga pagi
2. BHipoglisemia; kerap memeriksa glukosa dan mengikut pelan perlindungan glukosa
3. CTiada risiko; insulin hanya akan disimpan sehingga suapan bermula semula
4. DHiperglisemia; memberikan dos insulin tambahan serta-merta

Which burn should usually be discussed with a specialist burns service even if it is small?

1. AA tiny burn on the forearm with redness only
2. BA partial-thickness burn on the hand
3. CA healed burn scar from many years ago
4. DA small superficial sunburn on the back

Seorang berumur 74 tahun dengan penyakit buah pinggang kronik mengalami kesakitan teruk selepas pembedahan. Isu opioid manakah yang paling penting?

1. AMorfin ialah opioid paling selamat dalam kegagalan buah pinggang, jadi dos boleh dinaikkan dengan bebas
2. BMetabolit morfin terkumpul, jadi dos yang lebih rendah atau opioid lain mungkin diperlukan
3. COpioid tidak boleh sekali-kali digunakan pada warga emas, apa pun kesakitannya
4. DFungsi buah pinggang tidak memberi kesan terhadap cara opioid dikendalikan