Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Seorang jururawat mendelegasikan tanda vital rutin kepada pembantu jururawat untuk pesakit yang tekanan darahnya telah menurun sejak sejam lalu. Hak pendelegasian manakah yang tidak dipenuhi?

1. ATugas yang betul, kerana tanda vital tidak boleh didelegasikan
2. BArahan dan komunikasi yang betul
3. CKeadaan yang betul
4. DOrang yang betul

An infant with pyloric stenosis has repeated projectile vomiting. Which acid-base imbalance is most likely?

1. ARespiratory alkalosis
2. BMetabolic alkalosis
3. CMetabolic acidosis
4. DRespiratory acidosis

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

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

A nurse teaches new parents about safe infant sleep. Which statement shows a need for further teaching?

1. A“We will put a soft bumper pad and a blanket in the crib so the baby is cozy.”
2. B“We will keep the crib in our room, next to our bed, for the first months.”
3. C“We will lay the baby on the back for every sleep, including naps.”
4. D“We will not smoke near the baby.”

A patient receiving chemotherapy has an ANC of 300/µL and a new temperature of 38.3 °C (100.9 °F). What should the nurse do first?

1. ARemove extra blankets and offer a tepid sponge bath
2. BReport it at once so cultures and antibiotics start quickly
3. CEncourage oral fluids and record the fever in the chart
4. DGive acetaminophen (paracetamol) and recheck the temperature in 4 hours

Four drug levels are reported. Which patient should the nurse assess first?

1. APhenytoin 15 mcg/mL with no symptoms
2. BLithium 1.8 mEq/L with a new coarse tremor
3. CDigoxin 1.0 ng/mL with a pulse of 72/min
4. DValproate 75 mcg/mL with no symptoms

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

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

Pesakit dengan pendarahan GI akut mempunyai kadar jantung 120/min dan tekanan darah 90/60 mmHg. Apakah keutamaan kejururawatan selepas memanggil bantuan?

1. ATangguhkan tindakan sehingga warna najis disemak
2. BDapatkan akses IV bergarisan besar dan sediakan untuk penggantian cecair atau darah
3. CBeri hidangan besar untuk memulihkan tenaga
4. DGalakkan berjalan ke bilik air bersendirian

Which patient is most typical of a primary spontaneous pneumothorax?

1. AA middle-aged woman with high blood pressure
2. BA tall, thin young man who smokes
3. CAn older woman with long-standing heart failure
4. DA child with a viral sore throat

A frightened young woman is breathing fast and has tingling fingers. Her blood gas shows pH 7.50 and a low PaCO₂. SpO₂ is 99% on air. What does this show?

1. ARespiratory acidosis from hypoventilation
2. BMetabolic alkalosis from vomiting
3. CMetabolic acidosis from kidney failure
4. DRespiratory alkalosis from hyperventilation

Seminggu selepas pembedahan tiroid, suara pesakit masih serak dan lemah. Komplikasi manakah yang paling mungkin?

1. ATindak balas alergi terhadap pita pelekat pembalut
2. BKerosakan pada saraf laringeal berulang
3. CKalsium rendah akibat kecederaan paratiroid
4. DRibut tiroid yang dicetuskan oleh pembedahan

A nurse teaches a patient about peritoneal dialysis. Which statement shows a need for further teaching?

1. A"If the fluid is cloudy, I'll see if it clears next time."
2. B"I will weigh myself daily and record my fluid balance."
3. C"I will wash my hands carefully before each exchange."
4. D"I will check my exit site every day."

Which lifestyle change most improves the course of Crohn's disease?

1. AAvoiding all exercise
2. BDrinking more coffee
3. CEating more red meat
4. DStopping smoking

After a high-voltage electrical injury, a patient's urine is dark red-brown. What does this suggest and what is the usual aim?

1. ANormal concentrated urine; restrict fluids
2. BBleeding from the bladder; stop all fluids
3. CA urinary infection; send a sample and wait for the result
4. DMyoglobin from muscle damage; a higher urine output target