Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Menggunakan Emergency Severity Index, pesakit manakah yang menerima tahap ketajaman tertinggi?

1. APesakit yang tidak responsif dengan nafas tercungap-cungap dan tidak teratur
2. BPesakit dengan sakit dada dan tanda vital normal
3. CPesakit dengan kemungkinan patah buku lali
4. DPesakit dengan sakit tekak selama tiga hari dan tanda vital normal

Seorang jururawat menganggap dos yang ditetapkan tidak selamat. Pemreskripsi menyuruh memberikannya juga. Apakah yang patut dilakukan oleh jururawat?

1. ATahan dos dan eskalasi melalui rantaian pemerintahan
2. BLangkau dos secara senyap dan tidak berkata apa-apa untuk mengelakkan konflik
3. CBeri separuh dos sebagai kompromi dan dokumenkan sebabnya
4. DBeri dos itu, kerana pemreskripsi kini bertanggungjawab atasnya

Mengapakah ubat cecair oral diberikan dengan picagari oral atau enteral dan bukannya picagari IV piawai?

1. ATiada sebab keselamatan; ia hanya tradisi
2. BPicagari oral tidak muat pada talian IV, mencegah kesilapan laluan yang salah
3. CPicagari IV tidak dapat menyukat isi padu kecil cecair oral dengan tepat
4. DPicagari oral menyukat dos intravena dengan lebih tepat

A nurse teaches the daughter of a patient with moderate Alzheimer’s disease about home safety. Which statement shows a need for further teaching?

1. A“I keep her medicines locked away and give each dose to her myself.”
2. B“She wears an ID bracelet in case she gets lost.”
3. C“We put locks high up on the outside doors.”
4. D“I let Mom cook alone on the gas stove because she enjoys it.”

How often is the INR usually checked when warfarin is first started?

1. AEvery few days, until it is stable
2. BOnce a year, at a routine visit
3. CEvery hour, during the first week
4. DOnly if bleeding occurs at home

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 blood results are typical of Addison's disease (primary adrenal insufficiency)?

1. ALow haemoglobin and high platelets
2. BHigh glucose and high calcium
3. CHigh sodium and low potassium
4. DLow sodium and high potassium

Pesakit pascaoperasi mempunyai kadar jantung 115/min, suhu 38.6 °C, kadar pernafasan 26/min dan tekanan darah 85/50 mmHg walaupun telah diberi bolus cecair. Apakah yang paling mungkin ditunjukkan oleh ini?

1. ADehidrasi ringan sahaja
2. BKejutan septik yang memerlukan semakan rawatan rapi segera
3. CTindak balas keradangan normal pada hari-hari pertama selepas pembedahan
4. DKebimbangan tentang pelepasan

After repair of an abdominal aortic aneurysm, which regular assessment helps detect a blocked graft or clots in the legs?

1. AMeasuring the blood glucose every hour through the night
2. BChecking the pupils' response to light
3. CTesting the gag reflex every four hours after surgery
4. DChecking leg pulses, colour, warmth and sensation

A patient on an unfractionated heparin infusion has a nosebleed that will not stop, and the aPTT is far above the target range. What is the most appropriate action?

1. AGive vitamin K and continue the infusion at a slightly lower rate
2. BStop the infusion, inform the prescriber and anticipate protamine
3. CIncrease the infusion, as the aPTT will settle
4. DContinue the infusion at the same rate and pack the nose firmly

How does bladder training help urge incontinence?

1. AThe patient drinks as little as possible
2. BA catheter is used every night
3. CThe time between voids is slowly increased
4. DThe patient goes to the toilet every 15 minutes

Seorang pesakit hipotiroidisme yang tidak mengambil ubat selama berminggu-minggu dimasukkan ke wad dalam keadaan hipotermia dan mengantuk, dengan nadi 46/min, natrium rendah dan PaCO₂ meningkat. Keadaan manakah yang paling mungkin?

1. AKrisis adrenal
2. BKoma miksedema
3. CRibut tiroid
4. DStrok haba

Apakah keutamaan pertama apabila pesakit tiba di bilik pemulihan selepas anestesia am?

1. APembalut luka dan saliran
2. BSejarah ubat
3. CSeteguk air
4. DSaluran udara dan pernafasan

Which group of signs suggests that a patient is entering the last days of life?

1. AClearer thinking and increased movement
2. BRising appetite, more energy and normal skin colour and warmth
3. CReduced intake, mottled skin and changes in breathing
4. DHigh blood pressure and very fast weight gain