Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Seorang pembantu jururawat menolak tugas yang didelegasikan, dengan berkata dia belum dilatih melakukannya. Apakah respons terbaik daripada jururawat?

1. AMeninggalkan tugas itu untuk syif seterusnya, apabila ada orang terlatih yang bertugas
2. BBerterima kasih kepada pembantu, pastikan tugas dilakukan dengan selamat dan aturkan latihan
3. CMelaporkan pembantu kepada pengurus kerana menolak tugas
4. DMemberitahu pembantu bahawa ia ada dalam huraian kerja dan mesti dilakukan

Di unit kardiak, pesakit manakah yang patut dilihat dahulu oleh jururawat?

1. APesakit yang diminta berpuasa sebelum imbasan esok
2. BPesakit fibrilasi atrium yang kadar denyutan jantungnya 88/min dan tidak teratur, seperti sebelumnya
3. CPesakit yang mengambil digoksin dengan nadi 48/min, loya dan kalium 3.0 mEq/L
4. DPesakit kegagalan jantung yang bertambah 0.3 kg sejak semalam

A patient has a non-violent restraint. In most nursing policies, how often at minimum is it released for range of motion, toileting and skin care?

1. AAt least every 2 hours
2. BOnce a day, during the bath
3. COnce every 12-hour shift
4. DOnly when the patient asks for it

A patient refuses to wear an identification wristband. What should the nurse do?

1. AExplain why it is needed, use other ID methods per policy and document
2. BAccept the refusal and identify the patient by room number and bed space instead
3. CForce the band onto the patient’s wrist
4. DStop giving the patient any care until they agree to wear the band

Why must a blue-top (citrate) coagulation tube be filled to the correct level?

1. AAn overfull tube is needed to measure the potassium level
2. BThe blood-to-anticoagulant ratio must be right for accurate clotting times
3. CUnderfilled tubes always give a falsely low hemoglobin and hematocrit
4. DThe laboratory charges extra when a tube is not filled correctly

A patient with a serum albumin of 1.9 g/dL (19 g/L) has signs of phenytoin toxicity, although the total phenytoin level is in the usual range. What is the most likely explanation?

1. ALow albumin makes the liver clear phenytoin much faster
2. BLow albumin raises the free (active) fraction of phenytoin
3. CLow albumin makes the total level falsely high in all cases
4. DLow albumin stops phenytoin from crossing into the brain

Seorang pesakit pascaoperasi mempunyai kadar jantung 125/min, tekanan darah 88/50 mmHg dan pembalut yang basah dengan darah. Apakah yang sedang berlaku?

1. AKejutan septik akibat jangkitan kencing
2. BTindak balas sakit yang normal
3. CKejutan hipovolemik akibat pendarahan
4. DKebimbangan sahaja

A healthcare assistant reports four observations. Which one needs the nurse's immediate action?

1. A"Mr Patel's breathing rate is 8 a minute and he's hard to wake."
2. B"Ms Ali has walked to the bathroom on her own."
3. C"Mrs Jones would like a cup of tea and her glasses cleaned."
4. D"Mr Chen's blood pressure is 128/80 as usual."

How is orthostatic (postural) hypotension usually assessed?

1. ABP in both arms at the same moment while sitting
2. BBP only standing, after a brisk walk along the corridor
3. CBP once sitting, then once lying down straight after a large meal
4. DBP lying after rest, then again after 1 and 3 minutes standing

The monitor shows a regular broad-complex tachycardia at 180/min. The patient is alert with BP 126/78 mmHg and no chest pain. What is the most appropriate plan?

1. ARecord a 12-lead ECG, call senior help and anticipate an antiarrhythmic
2. BDeliver an unsynchronised shock immediately, before any other assessment
3. CStart chest compressions straight away and give a dose of IV adrenaline
4. DReassure the patient, as this is a normal rhythm

Selepas kecederaan kepala, seorang pesakit mempunyai cecair jernih menitis dari hidung. Apakah kebimbangan utama?

1. ATindak balas alergi terhadap kontras CT
2. BKebocoran CSF akibat keretakan tengkorak
3. CHingus normal yang terhasil selepas menangis
4. DSelesema biasa atau serangan demam hay

A patient with an external ventricular drain sat up in bed without help. The drain stayed at its old height, and the drainage bag filled quickly. The patient now has a headache. What is the concern?

1. AAn infected drain, so the dressing should be removed
2. BNo concern, because more drainage always lowers the ICP safely
3. CUnderdrainage, so the drain should be lowered further
4. DOverdrainage of CSF, so act per protocol and inform the team

How should a patient with facial burns usually be positioned?

1. ALying face down on the pillow to protect the airway
2. BLying flat with the head lower than the feet
3. CWith the head of the bed raised to reduce swelling
4. DIn any position that keeps the face covered

Semasa resusitasi lecuran, pengeluaran air kencing seorang dewasa 80 kg ialah 15 mL/j selama 2 jam. Apakah yang ditunjukkan oleh ini?

1. APengeluaran air kencing yang normal bagi pesakit lecur
2. BLebihan cecair; semua cecair IV patut dihentikan sekarang
3. CResusitasi yang tidak mencukupi; kadar cecair biasanya perlu dinaikkan
4. DKateter tersumbat yang patut dikeluarkan sahaja