Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Seorang jururawat mendapati pesakit di atas lantai bersebelahan katil. Apakah tindakan pertama?

1. AMenilai pesakit untuk responsif dan kecederaan sebelum menggerakkannya
2. BMembantu pesakit terus kembali ke katil dengan bantuan rakan sekerja
3. CMelengkapkan laporan insiden semasa butirannya masih segar
4. DMenghubungi keluarga pesakit untuk menerangkan apa yang berlaku

A 2-month-old infant has a spiral fracture of the femur. The parents say the baby rolled off the sofa. What should the nurse recognize?

1. AInfants of this age often roll off furniture and break bones in this way
2. BA spiral fracture in an infant is always caused by birth trauma
3. CThe injury does not fit the infant’s development, so possible abuse must be reported
4. DNo further action is needed once the fracture is treated

An older adult has trouble getting in and out of the bath. Which measures make bathing safer?

1. AA shower chair, grab bars and a non-slip mat
2. BBath oil to help the person slide in and out
3. CLocking the bathroom door for privacy
4. DA loose rug beside the tub to stand on

Seorang pesakit dipreskripsikan hidralazin, tetapi farmasi menghantar hidroksizin. Apakah yang patut dilakukan oleh jururawat?

1. AMemberikannya sekarang dan memberitahu pempreskripsi kemudian
2. BMemberikannya, kerana kedua-dua nama ubat itu hampir sama
3. CMemberikan separuh dos hidroksizin sebagai kompromi
4. DTidak memberikannya, dan menghubungi farmasi untuk mendapatkan ubat yang betul

Nilai makmal manakah yang paling baik menggambarkan punca kekeliruan pada pesakit dengan penyakit hati yang teruk dan getaran mengibas?

1. ATroponin yang meningkat
2. BLipase serum yang rendah
3. CAmmonia serum yang meningkat
4. DKalium serum rendah sahaja

A patient recovering from acute tubular necrosis now passes 4–5 L of urine a day. Which electrolyte changes should the nurse watch for?

1. ALow potassium and low sodium from urine losses
2. BHigh potassium and high sodium from retention
3. CNo changes, because the kidneys are now normal
4. DHigh calcium and high phosphate from bone loss

A nurse suspects that an older patient is being financially abused by a relative. What should the nurse do?

1. AConfront the relative directly at the bedside about it
2. BRaise the concern through the local safeguarding (adult protection) procedure
3. CKeep it secret because it is a family matter
4. DWait until the patient has been discharged

A patient with a confirmed pulmonary embolism is started on anticoagulation. Which statement best explains its purpose?

1. AIt is mainly given to lower the blood pressure
2. BIt dissolves the clot completely within minutes of the first dose being given
3. CIt stops the clot growing and prevents new clots while the body breaks it down
4. DIt thins the blood so that the lungs absorb more oxygen

Why is a higher level of HDL cholesterol considered protective?

1. AHDL is converted into vitamin D in the walls of the arteries
2. BHDL lowers the blood pressure directly
3. CHDL thins the blood in the same way as an anticoagulant
4. DHDL carries cholesterol from the tissues back to the liver

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

Which signs suggest rejection of a kidney transplant?

1. AA rash on the face after sun exposure
2. BMore urine, a falling creatinine and weight loss
3. CA cough, wheeze and a runny nose with sneezing
4. DLess urine, a rising creatinine and a tender graft

A patient taking digoxin has a potassium of 2.9 mmol/L. Why is this especially dangerous?

1. ALow potassium increases the risk of digoxin toxicity
2. BDigoxin raises the potassium to dangerous levels
3. CLow potassium makes digoxin leave the body faster
4. DDigoxin stops working when potassium is low

Tanda manakah yang menunjukkan pankreatitis akut yang teruk dengan pendarahan ke dalam tisu?

1. APerubahan warna kuning pada kuku jari
2. BLebam di sekeliling pusat atau rusuk
3. CBengkak pada bibir, lidah dan muka
4. DRuam ungu pada tapak tangan dan kaki

After surgery, a patient says they have "no pain" but grimaces, breathes shallowly and refuses to move or cough. What should the nurse do?

1. AExplore their beliefs and explain how analgesia aids recovery
2. BInsist they walk without any analgesia
3. CAccept the statement and record a pain score of 0
4. DTell the patient firmly that they must stop hiding their pain from staff