Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A nursing assistant tells the RN that a patient’s IV pump is alarming. What is the best response?

1. A“Turn the pump off and on again until it stops.”
2. B“Increase the rate a little so the alarm clears.”
3. C“Silence the alarm and I will check it at the end of the shift.”
4. D“I will come and check the pump and the IV site now.”

During surgery under general anesthesia, a patient develops rising end-tidal carbon dioxide, muscle rigidity and a rapidly increasing temperature. Which drug should the nurse anticipate?

1. AFlumazenil
2. BNaloxone
3. CAtropine
4. DDantrolene

The laboratory calls with a critical lab result by phone. What should the nurse do?

1. AWait for the printed report to arrive before telling the provider about it
2. BRemember the value and enter it in the chart at the end of the shift
3. CTell the patient the result first and then call the provider
4. DWrite it down, read it back to confirm and report it to the provider promptly

A patient on chemotherapy develops shingles over several areas on both sides of the body. Which precautions are needed?

1. AAirborne and contact precautions until all lesions are crusted
2. BStandard precautions only, with the lesions covered
3. CContact precautions only, with gloves for dressing changes
4. DDroplet precautions until the pain settles

Which technique is recommended for a capillary blood glucose test on an adult's finger?

1. ASqueeze the finger very hard
2. BUse the same finger every time
3. CPrick the center of the fingertip
4. DPrick the side of the fingertip

A patient with acute kidney injury has a potassium of 6.8 mEq/L despite medical treatment, a pH of 7.12 and pulmonary edema not responding to diuretics. Which treatment is most likely needed?

1. AUrgent dialysis
2. BA potassium supplement
3. CAn IV magnesium dose
4. DMore oral fluid

A spontaneously breathing patient is critically ill and hypoxic. Which oxygen delivery gives the highest concentration?

1. AVenturi mask set to 24%
2. BNasal cannula at 2 L/min
3. CSimple face mask at 5 L/min with the patient sitting up
4. DNon-rebreathe mask with reservoir bag at 15 L/min

Four call bells ring at the same time. Which patient should the nurse see first?

1. AA patient asking for pain relief for chronic back pain that they rate as 3/10
2. BA patient who has just become breathless after starting an IV antibiotic
3. CA patient who needs help to go to the toilet and has rung twice
4. DA patient asking what time they will be discharged

Seorang pesakit yang mengambil warfarin mula makan salad bayam dan kale dalam jumlah besar setiap hari. Apakah kebimbangan utama?

1. ASayur-sayuran hijau merosakkan hati semasa mengambil warfarin
2. BVitamin K tambahan mungkin meningkatkan INR
3. CTiada interaksi antara makanan dengan warfarin
4. DVitamin K tambahan mungkin merendahkan INR

On a ventilated patient, the end-tidal CO₂ waveform suddenly drops to zero. What should the nurse suspect first?

1. AA rise in the patient's body temperature over the last hour
2. BA sudden improvement in the patient's lung function
3. CNormal variation that needs no action
4. DTube displacement, disconnection or obstruction

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

After a TURP, a patient on bladder irrigation has bladder spasms. The drainage has slowed and contains clots, and the bag holds less than the irrigant given. What should the nurse do first?

1. ASuspect a clot in the catheter and follow the protocol
2. BEncourage the patient to strain to pass the clots
3. CGive an antispasmodic and recheck in four hours
4. DTurn off the irrigation and leave the catheter alone

How can low-dose opioids help a patient with breathlessness from advanced cancer?

1. AThey open the airways like an inhaler
2. BThey cure the underlying lung disease
3. CThey reduce the feeling of breathlessness
4. DThey increase the oxygen level in the blood

A patient with diabetes has rapidly spreading redness around a small wound, severe pain out of proportion, fever and crackling under the skin. What should the nurse suspect?

1. AA simple insect bite
2. BNecrotising fasciitis
3. CMild contact dermatitis
4. DA healing venous ulcer