Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Seorang jururawat yang biasanya bekerja dalam obstetrik ditugaskan sementara ke unit perubatan dewasa. Pesakit manakah yang paling sesuai ditugaskan kepada jururawat ini?

1. APesakit pneumonia yang stabil dengan antibiotik oral
2. BPesakit dengan infusi insulin berterusan untuk ketoasidosis diabetes
3. CPesakit dengan trakeostomi baharu
4. DPesakit dengan pendarahan gastrousus atas yang aktif

A patient who is 7 weeks pregnant has one-sided lower abdominal pain, pain in the shoulder tip, a heart rate of 120/min and a blood pressure of 88/54 mmHg. What is most likely?

1. AA ruptured ectopic pregnancy
2. BSevere morning sickness
3. CA urinary tract infection
4. DA normal early pregnancy

A nurse gives part of a dose of an opioid from a vial and must discard the rest. What is correct?

1. AReturn the rest to the patient’s medication drawer
2. BKeep the rest for the patient’s next dose
3. CDiscard it in front of a second licensed (registered) nurse, who witnesses and documents it
4. DDiscard it alone in the sink and document the amount wasted later in the shift

An 82-year-old patient is prescribed diphenhydramine at bedtime for sleep. Why should the nurse raise this with the prescriber?

1. AIt is strongly anticholinergic and can cause confusion and falls in older adults
2. BIt is only available as an IV drug and cannot be given by mouth at bedtime
3. CIt is too weak to help an older person sleep
4. DIt raises blood pressure in most older adults

A patient with central diabetes insipidus starts desmopressin. Which laboratory result is most important to monitor for an adverse effect?

1. ASerum sodium, which may fall too low
2. BSerum potassium, which may rise too high
3. CSerum calcium, which may rise too high
4. DSerum glucose, which may rise very high

Seorang pesakit dengan natrium 132 mEq/L dan glukosa darah 600 mg/dL (33.3 mmol/L) dimasukkan ke hospital. Mengapakah nilai natrium ditafsir dengan berhati-hati?

1. AGlukosa tidak mempunyai kesan pada natrium yang diukur
2. BKeputusan natrium mesti ralat makmal
3. CGlukosa tinggi menaikkan natrium yang diukur secara palsu, maka sebenarnya ia lebih rendah
4. DGlukosa tinggi menarik air ke dalam darah, mencairkan natrium

A patient with Guillain–Barré syndrome has weakness spreading upwards from the legs. Which monitoring is most important?

1. AVisual acuity
2. BBlood glucose, measured once a day before breakfast
3. CBreathing function, such as forced vital capacity
4. DWeekly weight

A patient with severe sepsis starts bleeding from cannula sites and the gums, with a low platelet count and prolonged clotting times. What is most likely?

1. AVitamin C deficiency
2. BDisseminated intravascular coagulation
3. CAn allergic reaction to the cannula
4. DHaemophilia A

A patient who had a leg amputation says they feel burning pain in the missing foot. What is the best response?

1. AAdvise that it will be ignored until it stops
2. BExplain that phantom limb pain is real and arrange treatment
3. CExplain that burning pain in the missing foot shows wound infection
4. DTell the patient the pain must be imaginary as the foot has gone

A one-way speaking valve is fitted to a patient's tracheostomy tube while the cuff is still inflated. What is the danger?

1. AThe patient will speak too loudly
2. BThe valve will humidify the air too much
3. CThe patient cannot breathe out and may suffocate
4. DThere is no danger, as the valve works with any cuff

A patient on peritoneal dialysis has gained weight and has higher glucose levels. Which part of the treatment is the likely cause?

1. AAir entering the abdomen during exchanges
2. BSodium lost into the dialysis fluid
3. CGlucose absorbed from the dialysis fluid
4. DProtein lost into the dialysis fluid

After a stroke, a patient suddenly cries or laughs at odd moments. They say they do not feel sad. Which response is most appropriate?

1. AIgnore it, because it shows that the patient is seeking attention from the staff
2. BTell the patient that crying will slow their recovery
3. CExplain that this is emotional lability after stroke and help the family understand
4. DAsk the doctor for a sedative to stop the outbursts

After a spinal anaesthetic, which nursing check is particularly important?

1. ABlood glucose every 15 minutes overnight
2. BPeak flow before and after each meal
3. CReturn of leg sensation and movement, and passing urine
4. DPupil reaction every five minutes for the next full day

A patient took a large paracetamol (acetaminophen) overdose 6 hours ago and says they feel completely well. Which statement is correct?

1. ATreatment is not needed if the patient has not vomited
2. BLiver damage after paracetamol occurs only within the first hour or so
3. CFeeling well means the dose was too small to cause harm
4. DLiver damage may still develop, and appears only days later