Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Seorang jururawat menerima empat loceng panggilan pada masa yang sama. Pesakit manakah yang didatangi dahulu oleh jururawat?

1. APesakit yang bertanya pukul berapa doktor akan datang
2. BPesakit yang berkata, "Saya tidak dapat bernafas."
3. CPesakit yang meminta ubat penahan sakit untuk kesakitan 4/10
4. DPesakit yang pam IVnya berbunyi kerana beg cecair penyelenggaraan telah habis

A patient has a heart rate of 38/min, feels dizzy and has a blood pressure of 80/50 mmHg. Which drug is usually given first, as prescribed?

1. AMetoprolol
2. BAtropine
3. CDiltiazem
4. DDigoxin

Why can side rails be dangerous for a confused, restless patient?

1. ASide rails make the bed move by itself
2. BSide rails stop staff from reaching the patient in an emergency
3. CThe patient may climb over them or get trapped in gaps
4. DSide rails always cause pressure injuries

Ten minutes into a red blood cell transfusion, the patient reports chills and low back pain and has a new fever. What should the nurse do first?

1. ACall the blood bank and let the transfusion continue
2. BSlow the transfusion and recheck vital signs in 15 minutes
3. CGive an antipyretic and continue the transfusion
4. DStop the transfusion

Kiraan sel darah putih seorang pesakit ialah 16 × 10³/µL dengan perkadaran tinggi neutrofil yang belum matang (band). Apakah yang paling mungkin ditunjukkan oleh ini?

1. APenyakit virus kronik sahaja
2. BJangkitan bakteria akut
3. CKeputusan normal
4. DAnemia kekurangan zat besi

The nurse teaches a patient who is collecting a 24-hour urine sample at home. Which statement shows a need for further teaching?

1. A"I'll empty my bladder at the end time and add that urine"
2. B"I'll keep the container cool as the laboratory told me to"
3. C"I'll ask whether any foods or drugs should be avoided first"
4. D"If I forget to save one void, I'll just carry on to the end"

Which rule is essential for safe use of patient-controlled analgesia (PCA)?

1. AOnly the patient should press the button
2. BRelatives should press it while the patient sleeps
3. CThe button should be pressed before each meal
4. DThe nurse should press it every hour

A postoperative patient on IV fluids has a sodium of 128 mmol/L and is becoming confused. Which fluid could make this worse if given in large amounts?

1. AHartmann's solution (similar to lactated Ringer's)
2. B5% glucose (D5W)
3. CHuman albumin solution
4. D0.9% sodium chloride

Why is a shock for cardioversion synchronised with the QRS complex?

1. ATo allow the use of a lower battery charge
2. BTo avoid delivering the shock during the T wave
3. CTo keep the pads from burning the skin
4. DTo make the shock less painful for the patient

After intubation, breath sounds are heard on the right side of the chest but not the left. What is the most likely cause?

1. AThe tube has entered the oesophagus
2. BThe tube has entered the right main bronchus
3. CThe left lung has completely filled with fluid
4. DThe tube cuff has burst during insertion

A patient with a spinal cord injury can still feel a light touch around the anus. What does this show?

1. AThe sensation is only a spinal reflex and has no real meaning for recovery
2. BThe injury is incomplete, which suggests a better chance of recovery
3. CThe patient has an injury of the brain, not the cord
4. DThe injury is complete, and recovery is not possible

Six hours after a catheter is removed, a patient has not passed urine and feels uncomfortable. What should the nurse do?

1. APut the catheter back without assessing
2. BWait until the next morning before checking
3. CTell the patient to drink two litres of water quickly
4. DDo a bladder scan to check for retention

A patient has taken oral prednisolone daily for many months. Why is this important before surgery?

1. ASteroids make the anaesthetic drugs last much longer
2. BThey may need extra steroid cover to prevent an adrenal crisis
3. CSteroids must always be stopped a full week before any type of surgery
4. DSteroids prevent all wound infections after surgery

During a nasogastric feed, a patient starts coughing and SpO₂ falls from 96% to 89%. What should the nurse do first?

1. ALay the patient flat to help them rest
2. BIncrease the feed rate to finish it sooner
3. CStop the feed and assess the airway and breathing
4. DGive a drink of water to clear the throat