Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A patient wants to leave the hospital against medical advice. What should the nurse do?

1. ALock the door so the patient cannot leave the unit
2. BHide the patient’s clothes and belongings until the provider arrives
3. CLet the patient leave without telling anyone
4. DInform the provider, explain the risks and document the discussion

A patient has a potassium of 7.0 mEq/L with peaked T waves. Several drugs are prescribed. Which one is usually given first to protect the heart?

1. AIV furosemide
2. BOral potassium binder
3. COral sodium bicarbonate
4. DIV calcium gluconate

What is the main aim of purposeful hourly rounding?

1. ATo wake the patient every hour to check orientation
2. BTo check pain, toileting, position and personal items before the patient needs to ask
3. CTo replace the need for a call light
4. DTo count the patient’s medications every hour and check that none are missing

A nurse teaches parents about using an infant car seat. Which statement shows a need for further teaching?

1. A“We will put the rear-facing seat in the front so we can see the baby.”
2. B“We will make sure the harness straps are snug against the baby’s chest.”
3. C“We will install the seat in the back seat, facing the rear.”
4. D“We will use the car seat for every trip, even short ones.”

A trauma patient receives 2 L of IV crystalloid. The hemoglobin falls from 13.0 to 11.4 g/dL (130 to 114 g/L), and the vital signs are now stable. Which explanation is most likely?

1. AIncreased red cell production
2. BDilution of the blood by the IV fluid
3. CA sudden failure of the bone marrow
4. DA laboratory error in the first sample

Four drug levels are reported. Which patient should the nurse assess first?

1. APhenytoin 15 mcg/mL with no symptoms
2. BLithium 1.8 mEq/L with a new coarse tremor
3. CDigoxin 1.0 ng/mL with a pulse of 72/min
4. DValproate 75 mcg/mL with no symptoms

Ubat manakah yang digunakan untuk membalikkan heparin tak terpecah?

1. ANalokson
2. BFlumazenil
3. CProtamin sulfat
4. DVitamin K (fitomenadion)

A nurse teaches a patient with diabetes about foot care. Which statement shows a need for further teaching?

1. A"I will check my feet every day for cuts or blisters."
2. B"I will see the podiatrist about hard skin."
3. C"I will walk barefoot at home to toughen my feet."
4. D"I will wear well-fitting shoes."

After an arterial blood gas sample is taken from the radial artery, what should the nurse do?

1. AApply firm pressure to the site for several minutes
2. BLeave the site uncovered without pressure
3. CBend the wrist sharply upwards to stop the bleeding
4. DMassage the site to help the bruising fade

Sebelum dos digoksin pada pagi hari, nadi apeks pesakit ialah 54/min dan pesakit berasa loya. Apakah yang patut dilakukan oleh jururawat?

1. AMemberikan separuh dos dan menyemak semula nadi dalam sejam
2. BMemberikan dos dan antiemetik, kemudian menyemak semula nadi esok
3. CMenahan dos dan melaporkannya, kerana ketoksikan mungkin berlaku
4. DMemberikan dos, kerana hanya nadi radial yang dikira

A patient with Graves' eye disease has gritty eyes and swelling around them in the morning. Which advice is most appropriate?

1. AStay in bright sunlight to dry the eyes
2. BUse lubricating drops and sleep with the head raised
3. CSmoking more will not affect the eyes
4. DRub the eyes firmly each morning to reduce the swelling

A patient with stable epilepsy on phenytoin started a new medicine last week. They now have nystagmus, an unsteady gait and slurred speech. What should the nurse do?

1. ASuspect phenytoin toxicity, hold the next dose and ask for a drug level
2. BEncourage the patient to walk more to improve their balance
3. CGive the next phenytoin dose early to prevent a seizure
4. DSuspect a new stroke and give aspirin straight away before any scan

How are skin staples usually removed from a healed incision?

1. AAlternate staples first, then the rest if the wound holds
2. BOnly the staples at each end, leaving the others for good
3. CAll staples at once by pulling each one straight up from the skin
4. DThe staples are left in permanently under the skin

Four patients from a house fire arrive in the emergency department. Which should the nurse assess first?

1. AA blistered forearm burn and a small cut on the knee
2. BPartial-thickness burns to both legs, with pain rated 8/10
3. CRedness on the backs of both hands, and very anxious
4. DCircumferential chest burns, with breathing becoming shallow and laboured