Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

An older patient with dementia is restless at night and keeps trying to get out of bed. Which measure should the nurse try first?

1. AGive a sedative from the as-needed list without first assessing the patient
2. BCheck for pain, thirst or a full bladder, and offer toileting
3. CRaise all four bed rails so the patient cannot climb out
4. DApply wrist restraints for the rest of the night

Discaj yang dirancang bagi pesakit manakah yang patut dipersoalkan oleh jururawat?

1. APesakit selepas pembaikan hernia yang sedang membuang air kecil dan makan
2. BPesakit dua hari selepas pembedahan dengan kadar denyutan jantung baharu 112/min dan suhu 38.4 °C
3. CPesakit dengan simen yang stabil yang berjalan dengan selamat menggunakan tongkat ketiak
4. DPesakit pneumonia yang tidak demam selama 48 jam dengan antibiotik oral

An order reads “Give potassium chloride by IV push.” What should the nurse do?

1. AGive half by IV push and the rest later
2. BNot give it, and contact the prescriber, because it is never given by IV push
3. CGive it slowly by IV push over two minutes while watching the cardiac monitor
4. DDilute it in a small syringe and push it

A patient’s WBC is 4,000/mm³, with 30% neutrophils and 5% bands. What is the absolute neutrophil count (ANC)?

1. A3,500/mm³
2. B1,200/mm³
3. C140/mm³
4. D1,400/mm³

Which instruction is correct for a patient taking an oral potassium chloride supplement?

1. AUse a salt substitute as well, so less of the tablet is needed each day
2. BTake it with food and a full glass of water, and do not crush extended-release tablets
3. CCrush the extended-release tablets and mix them with a little water if needed
4. DTake it on an empty stomach with only a small sip of water to speed absorption

A patient's bedside glucose meter shows "HI" (above its measuring range). The patient is drowsy. What should the nurse do?

1. ARecord "HI" and repeat the meter test at the next scheduled time
2. BGive oral glucose in case the reading is wrong and the patient is low
3. CSend a venous sample to the lab and inform the provider at once
4. DAssume the meter is broken and give the usual insulin dose

What happens in third-degree (complete) heart block?

1. AThe ventricles beat very fast and regularly
2. BThe atria beat chaotically with no P waves, and the ventricular rate is irregular
3. CEvery impulse reaches the ventricles, but each one is slightly delayed
4. DNo impulses from the atria reach the ventricles, so they beat independently

During a general anaesthetic, a patient develops a rapidly rising temperature, muscle rigidity and rising carbon dioxide levels. What should be suspected?

1. AA normal response to surgery
2. BNeuroleptic malignant syndrome from antipsychotics
3. CPostoperative infection
4. DMalignant hyperthermia

A patient has pneumonia in the right lung only. In which side-lying position will oxygenation usually be best?

1. AProne with the head down
2. BLying on the left side, with the healthy lung down
3. CFlat on the back with no pillows
4. DLying on the right side, with the affected lung down

Four hours after abdominal surgery, a patient's heart rate has risen from 84 to 122/min and they are restless and pale. BP is still 118/76 mmHg, and the surgical drain is filling with blood. What should the nurse conclude?

1. AEarly haemorrhagic shock is likely, so escalate urgently
2. BThe patient is stable because the blood pressure is normal
3. CThe drain is working well, so no action is needed
4. DThe tachycardia is from pain and needs only analgesia

A patient taking a GLP-1 receptor agonist has severe, constant upper abdominal pain spreading to the back, with vomiting. What should the nurse suspect?

1. AA simple urinary tract infection
2. BAcute pancreatitis
3. CNormal nausea from the drug
4. DLow blood glucose

The nurse has four patients with diabetes. Which one needs to be seen first?

1. AA patient waiting for a routine HbA1c test
2. BA patient with a glucose of 2.8 mmol/L (50 mg/dL) who is sweaty and confused
3. CA newly diagnosed patient asking about which foods to eat
4. DA patient with a glucose of 14 mmol/L (252 mg/dL) who feels well and is eating

Which burn should usually be discussed with a specialist burns service even if it is small?

1. AA healed burn scar from many years ago
2. BA tiny burn on the forearm with redness only
3. CA partial-thickness burn on the hand
4. DA small superficial sunburn on the back

A patient with a severe flare of ulcerative colitis develops abdominal distension, fever and tachycardia, and the stool frequency has dropped. What should the nurse suspect?

1. AToxic megacolon
2. BHaemorrhoids caused by diarrhoea
3. CThe flare is getting better
4. DSimple constipation from low intake