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

A patient has full-thickness burns all the way around the chest and is finding it harder to breathe, although the airway is clear. What does this suggest?

1. AThe burns are healing and the skin is tightening normally
2. BThe tight burned skin is restricting chest movement, so an escharotomy may be needed
3. CThe patient has had too little IV fluid and needs a fast bolus to improve the breathing
4. DThe patient is anxious and only needs reassurance

Before inserting a peripheral IV, the nurse cleans the skin with chlorhexidine-alcohol. What should the nurse do next?

1. AWipe it off with a dry gauze straight away
2. BFeel for the vein again with an ungloved finger
3. CLet it dry fully and do not touch the site again
4. DBlow on the site so it dries faster

A patient who speaks little English is being discharged with new medications. The patient’s 12-year-old child offers to interpret. What should the nurse do?

1. AUse a professional medical interpreter
2. BLet the child interpret, because the family prefers it
3. CGive written instructions in English only
4. DUse simple English and many hand gestures

A patient with chronic kidney disease has a potassium of 5.6 mEq/L. Which food should the nurse advise the patient to limit?

1. AApples
2. BCabbage
3. CBananas
4. DWhite rice

Semasa infusi magnesium sulfat IV, penilaian manakah yang paling baik mengesan ketoksikan lebih awal?

1. ARefleks lutut, kadar pernafasan dan keluaran air kencing
2. BGlukosa darah dan saiz anak mata setiap jam
3. CBunyi usus dan lilitan abdomen
4. DWarna kulit dan pengisian semula kapilari setiap jam

Which is the correct technique for using a metered-dose inhaler without a spacer?

1. ABreathe out, then breathe in slowly and deeply while pressing the canister, then hold
2. BPress the canister and wait one minute before breathing in
3. CBreathe in quickly through the nose while pressing the canister
4. DPress the canister twice quickly, then breathe in fast and breathe straight out again

A patient suddenly develops a painful red eye with blurred vision, haloes around lights and vomiting. What should be suspected?

1. ADry eye syndrome
2. BA stye
3. CSimple conjunctivitis from a viral infection
4. DAcute angle-closure glaucoma

A nurse measures blood pressure on a large upper arm using a cuff that is too small. What effect will this have?

1. AOnly the pulse rate will be affected
2. BThe reading will be accurate but slower
3. CThe reading will be falsely low
4. DThe reading will be falsely high

Seorang pesakit asma mempunyai aliran puncak 40% daripada yang terbaik, kadar pernafasan 28/min dan tidak dapat menghabiskan ayat. SpO₂ ialah 94%. Bagaimanakah serangan ini patut dikelaskan?

1. AAsma teruk akut
2. BAsma yang mengancam nyawa
3. CEksaserbasi asma sederhana
4. DAsma yang nyaris membawa maut

A patient uses a continuous glucose monitor. Which statement is correct?

1. AIt reads glucose in fluid under the skin, a little behind blood glucose
2. BIt makes finger-prick checks unnecessary in every situation
3. CIt measures glucose directly in the blood every second of the day
4. DIt works by giving small doses of insulin automatically

A man with chronic urinary retention is catheterised. Over the next hours he passes very large volumes of urine. What is the main nursing concern?

1. AA urinary infection caused by the high flow of urine
2. BA rise in blood glucose from the urine
3. CRupture of the bladder from the catheter
4. DFluid and electrolyte loss from post-obstructive diuresis

Which finding means a patient is usually ready to leave recovery for the ward?

1. AAwake, with a clear airway, stable observations and controlled pain
2. BSystolic BP falling steadily over the last hour, with a rising pulse rate
3. CStill drowsy and needing a jaw thrust to breathe
4. DPain score 9/10 and vomiting repeatedly

A nurse finds a dislodged sealed radiation source in the bed of a patient receiving brachytherapy. What should the nurse do?

1. AThrow it in the clinical waste bag
2. BLeave it in the bed until the end of the shift
3. CUse long-handled forceps to put it in the lead container; report it
4. DPick it up with gloved hands and put it in the nearest sharps bin quickly