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 tekak selama tiga hari dan tanda vital normal
3. CPesakit dengan kemungkinan patah buku lali
4. DPesakit dengan sakit dada dan tanda vital normal

An older patient with heart failure is receiving a second unit of blood. She becomes breathless, with crackles in both lungs and a rising blood pressure. What is most likely happening?

1. AA mild allergic reaction with hives
2. BAn expected effect of the first unit
3. CTransfusion-associated circulatory overload
4. DHypoglycemia caused by the stored blood product

A patient is on suicide precautions. Which room safety measure is appropriate?

1. ALet the patient keep a personal razor for shaving, as long as staff are told
2. BKeep the door closed at all times so the patient has privacy
3. CAllow glass bottles if the patient seems calm
4. DRemove items that could be used for self-harm, such as belts and cords

A patient dies after a wrong-drug error, and the hospital carries out a root cause analysis. What is its main focus?

1. AEstimating the legal costs for the hospital
2. BFinding the system and process weaknesses that allowed the error
3. CIdentifying which staff member made the error and should be disciplined
4. DDeciding whether to tell the family about the error

Seorang pesakit dengan sindrom rembesan hormon antidiuretik yang tidak sesuai (SIADH) mempunyai natrium 128 mEq/L. Langkah ditetapkan manakah yang dijangka oleh jururawat?

1. AMenggalakkan pengambilan air tambahan
2. BSekatan cecair
3. CIsi padu besar glukosa 5% IV
4. DDiet rendah natrium

Seorang pesakit tiba 30 minit selepas muntah darah dalam jumlah yang banyak. Kadar denyutan jantung ialah 125/min, tetapi hemoglobin pertama ialah 13.0 g/dL (130 g/L). Mengapakah hemoglobin itu mengelirukan?

1. AHemoglobin meningkat semasa pendarahan, yang menyembunyikan kehilangan itu
2. BNilai itu membuktikan tiada pendarahan yang ketara
3. CUjian ini tidak pernah tepat dalam situasi kecemasan
4. DDarah penuh telah hilang, maka paras hanya menurun beberapa jam kemudian

What should the nurse regularly check for a patient with a syringe driver?

1. AOnly the patient's weight, measured once a week on the same scales
2. BOnly that the battery is charged and the device is switched on
3. CNothing, once the syringe driver is running
4. DThe infusion site, the rate and volume remaining, and the patient's symptoms

A nurse phones a doctor about a deteriorating patient using SBAR. Which statement belongs in the "R" section?

1. A"Please review him within the next 15 minutes."
2. B"His blood pressure is 85/50 and he is confused."
3. C"He was admitted three days ago with pneumonia."
4. D"I am calling about Mr Smith, who is breathless."

A patient's blood pressure is high in clinic but normal on home readings. Which step best confirms the diagnosis?

1. AA chest X-ray
2. BA single repeat reading in the same clinic visit
3. CAmbulatory or structured home blood pressure monitoring
4. DStarting two antihypertensive drugs at once at full dose

A patient with pneumonia has a temperature of 39 °C, pain and a sinus tachycardia of 122/min. BP is normal. What is the best way to manage the heart rate?

1. AArrange urgent electrical cardioversion to restore a normal rate
2. BGive a beta-blocker to bring the heart rate below 100/min
3. CGive IV adenosine
4. DTreat the fever, pain and possible dehydration, then reassess

Which measure best detects a decline in breathing in a patient with Guillain–Barré syndrome?

1. AOxygen saturation alone
2. BDaily chest X-rays
3. CRegular forced vital capacity measurements
4. DPeak flow before and after a bronchodilator

During a water deprivation test for suspected diabetes insipidus, the patient loses more than 3% of body weight and becomes hypotensive. What should the nurse do?

1. AStop the test and inform the doctor
2. BGive the patient a large drink and then restart the test
3. CContinue the test, because this result is expected
4. DGive desmopressin without a prescription

Which advice may help reduce the risk of a parastomal hernia after stoma surgery?

1. AStrain hard on the toilet each day to strengthen the abdominal muscles
2. BAvoid heavy lifting early on and use support garments as advised
3. CKeep the stoma bag as full as possible
4. DDo intensive sit-ups from the first week

A patient arrives in recovery with a temperature of 35.2 °C and is shivering. What is the most appropriate action?

1. AGive cold IV fluids to settle the shivering
2. BRemove all blankets to let the body adjust
3. CSend the patient to the ward to warm up there under extra blankets
4. DStart active warming and monitor the temperature