Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Seorang jururawat melihat pembantu jururawat mengukur tekanan darah dengan kaf yang jelas terlalu kecil. Apakah yang patut dilakukan oleh jururawat?

1. AMengeluarkan pembantu daripada penjagaan pesakit untuk hari itu
2. BCampur tangan sekarang, betulkan teknik dengan bijaksana dan semak semula
3. CMenyebutnya kemudian pada penilaian tahunan pembantu yang seterusnya
4. DMengabaikannya, kerana satu bacaan tinggi tidak penting

A marathon runner is confused, with a temperature of 41 °C and hot skin. What is the priority?

1. ARapid cooling while supporting airway and circulation
2. BGiving an antipyretic tablet and waiting for it to work
3. CWrapping the runner in a blanket to prevent shivering
4. DAsking the runner to rest in the shade and drink slowly

Apakah yang patut dilakukan oleh jururawat selepas darah pesakit terpercik ke mata secara tidak sengaja?

1. AMenggosok mata perlahan-lahan dengan tisu bersih dan kering untuk membuang darah dahulu
2. BMenitiskan titis mata antibiotik dan tidak memberitahu sesiapa
3. CMenyiapkan prosedur, kemudian melapor pada hari berikutnya
4. DMembilas mata serta-merta dengan banyak air atau salin, kemudian melapor

A patient rescued from a house fire has a headache and confusion, but the pulse oximeter reads 99%. Why might this reading be misleading?

1. APulse oximetry cannot tell carbon monoxide-bound hemoglobin from oxygen-bound hemoglobin
2. BThe reading is accurate, so carbon monoxide poisoning is ruled out
3. CConfusion and headache make pulse oximetry readings inaccurate in every patient
4. DPulse oximeters always read falsely low after any kind of smoke exposure

Apart from the lithium level, which tests are monitored regularly in long-term lithium therapy?

1. AINR and the platelet count
2. BTroponin and creatine kinase (CK)
3. CKidney function and thyroid function
4. DLiver enzymes and serum amylase

Kalsium keseluruhan seorang pesakit ialah 7.9 mg/dL (2.0 mmol/L), dengan albumin 2.4 g/dL (24 g/L) dan tiada gejala. Ujian manakah yang paling baik menjelaskan sama ada hipokalsemia sebenar wujud?

1. AKalsium terion
2. BHbA1c
3. CGraviti tentu air kencing
4. DNatrium serum

What should the nurse regularly check for a patient with a syringe driver?

1. AOnly that the battery is charged and the device is switched on
2. BNothing, once the syringe driver is running
3. CThe infusion site, the rate and volume remaining, and the patient's symptoms
4. DOnly the patient's weight, measured once a week on the same scales

Why is a patient kept under observation for several hours after successful treatment of anaphylaxis?

1. AThe patient must stay until all allergy tests are complete
2. BAdrenaline always causes a heart attack hours later
3. CAntihistamines cause dangerous drowsiness for 24 hours
4. DSymptoms can return later in a biphasic reaction

When should an adult with cystic fibrosis take pancreatic enzyme capsules?

1. AOnly at bedtime
2. BWith all meals and snacks that contain fat
3. COnce a day on waking, at least an hour before any food
4. DOnly when they have diarrhoea

A nurse receives handover on four patients. Which patient should be seen first?

1. AA patient with pneumonia on IV antibiotics who now has a temperature of 38.2 °C
2. BA patient on day 1 after surgery who is newly restless, RR 30/min, SpO₂ 88% on 4 L/min
3. CA patient with COPD on 1 L/min whose SpO₂ has been 89% and stable throughout the night
4. DA patient with asthma who wants a reliever inhaler before a walk

Tindakan kejururawatan manakah yang membantu mencegah peningkatan tekanan intrakranial?

1. AMembaringkan pesakit mendatar dengan pinggul dibengkokkan secara tajam
2. BMencegah sembelit dan menjarakkan penjagaan
3. CMenggalakkan batuk kuat setiap jam
4. DMelakukan semua penjagaan dan penyedutan dalam satu sesi yang panjang

A patient taking digoxin has a potassium of 2.9 mmol/L. Why is this especially dangerous?

1. ADigoxin raises the potassium to dangerous levels
2. BLow potassium increases the risk of digoxin toxicity
3. CDigoxin stops working when potassium is low
4. DLow potassium makes digoxin leave the body faster

Which statement correctly describes physical dependence on opioids?

1. AThe patient is allergic to opioids
2. BThe patient always craves the drug and misuses it despite harm
3. CWithdrawal occurs if the drug is stopped suddenly
4. DThe drug no longer has any side effects

Seorang pesakit ileostomi tiada output selama 6 jam, dengan sakit kekejangan, kembung, loya dan stoma bengkak. Apakah yang patut disyaki oleh jururawat?

1. ATempoh senyap yang normal bagi ileostomi baharu
2. BSekatan stoma, selalunya akibat makanan, yang memerlukan semakan
3. CDehidrasi akibat output ileostomi yang sangat tinggi
4. DRuam kulit kecil di sekeliling stoma