Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Seorang jururawat berdaftar berkata kepada pembantu jururawat, "Tengok pesakit di bilik 12." Hak pendelegasian manakah yang tiada?

1. AArahan dan komunikasi yang betul
2. BOrang yang betul untuk tugas itu
3. CTugas yang betul untuk tetapan itu
4. DKeadaan yang betul

A trauma patient has an open leg fracture, absent breath sounds on one side, a trachea shifted to the other side and a falling blood pressure. Which problem is the priority?

1. AThe open fracture of the leg
2. BThe suspected tension pneumothorax
3. CThe pain from the fracture
4. DThe risk of wound infection

Langkah keselamatan pesakit manakah yang paling sesuai bagi pesakit yang alah kepada lateks?

1. AMenggunakan peralatan bebas lateks dan mendokumenkan alahan itu dengan jelas
2. BMenggunakan sarung tangan lateks berbedak sahaja
3. CMenggunakan sarung tangan lateks dan mencuci tangan dengan baik selepas itu
4. DMengelak semua sarung tangan semasa penjagaan pesakit

A nurse caring for a patient with influenza on droplet precautions will assist with an aerosol-generating procedure, such as bronchoscopy. What change in PPE is needed?

1. AWear two surgical masks, one on top of the other, for the length of the procedure
2. BWear gloves only, because the procedure is short
3. CWear a fit-tested respirator (N95 or FFP3) and eye protection instead of a surgical mask
4. DNo change, because influenza only needs droplet precautions

Sebelum memberi kalium klorida IV yang ditetapkan, penilaian manakah yang paling penting?

1. ASaiz anak mata dan tindak balas terhadap cahaya
2. BTurgor kulit pada lengan bawah
3. CKeluaran air kencing dan fungsi buah pinggang
4. DPendengaran di kedua-dua telinga

Seorang pesakit dengan infusi insulin IV mempunyai glukosa darah 65 mg/dL (3.6 mmol/L). Apakah tindakan terbaik?

1. AIkut protokol untuk glukosa rendah dan maklumkan pembekal
2. BHentikan infusi dan tinggalkan pemeriksaan semula glukosa sehingga pagi
3. CBeri kalium oral untuk melindungi jantung
4. DTeruskan pada kadar yang sama dan semak semula dalam empat jam

Why is an ankle–brachial pressure index (ABPI) measured before applying compression bandages to a leg ulcer?

1. ATo work out the patient's fluid needs
2. BTo exclude significant arterial disease, as compression could cut off blood flow
3. CTo measure how deep the ulcer is and how much exudate it produces
4. DTo check for a urinary tract infection that could delay ulcer healing

A patient going home after chemotherapy is taught about infection. Which statement shows a need for further teaching?

1. A"I will check my temperature if I feel unwell or shivery at home."
2. B"I will wash my hands well before eating and after using the toilet."
3. C"If I get a temperature, I'll take paracetamol and wait until my next clinic."
4. D"I will phone the helpline if I have a fever or shivering."

A patient with stable angina is afraid nicotine patches will harm their heart. Which reply is most accurate?

1. APeople with angina must stop smoking without any help
2. BNicotine replacement is much safer than smoking and is recommended
3. CNicotine replacement only works if smoking continues
4. DNicotine patches are much more harmful to the heart than cigarettes

After a fall onto the chest, part of a patient's chest wall moves inward when they breathe in and outward when they breathe out. What does this indicate?

1. AA large pleural effusion pressing on the chest wall
2. BA single simple rib fracture with no lung injury
3. CNormal chest movement caused by pain on breathing
4. DA flail chest from ribs broken in more than one place

Which nursing action helps most to prevent and manage delirium in an older inpatient?

1. AUse glasses and hearing aids and reorient the patient often
2. BRestrain the patient so that they do not wander off the ward
3. CKeep the lights on all night so the patient can see clearly
4. DMove the patient to a different room each day for variety

A patient with suspected meningitis has a GCS of 9 and pupils that have become unequal. A doctor plans an immediate lumbar puncture. What is the main concern?

1. AThere is no concern, because the lumbar puncture lowers pressure safely
2. BThe patient is too confused to stay still, so it is not needed
3. CRaised pressure in the skull, so the procedure could cause herniation
4. DA lumbar puncture would spread the infection to the blood

Why is it important to prevent perioperative hypothermia?

1. AIt lowers the risk of pain after surgery
2. BIt increases bleeding, wound infection and heart complications
3. CIt reduces the amount of anaesthetic needed, which is unsafe
4. DIt makes patients wake up from the anaesthetic too quickly

Seorang pesakit sirosis dengan asites mengalami demam baharu, abdomen sakit apabila disentuh dan kekeliruan yang bertambah teruk. Komplikasi manakah yang patut disyaki?

1. APerkembangan normal asites
2. BSembelit biasa
3. CPankreatitis akut
4. DPeritonitis bakteria spontan