Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A young adult has just started an SSRI antidepressant for major depression. What should the nurse monitor most closely in the first weeks?

1. AThoughts of suicide or self-harm
2. BRising blood glucose levels
3. CHair growth and skin color
4. DWeight loss from too much appetite

A patient with untreated hyperthyroidism has surgery and develops a temperature of 40 °C, a heart rate of 160/min and severe agitation. What is most likely happening?

1. AMyxedema coma
2. BA normal reaction to pain
3. COpioid withdrawal
4. DThyroid storm

A child has swallowed a button battery. Why is this urgent?

1. AIt always passes through the gut without harm
2. BIt can burn through the lining of the esophagus within hours
3. CIt is only harmful if several batteries are swallowed
4. DThe only risk is poisoning from heavy metals years later

Seorang jururawat hendak memberikan morfin IV. Kadar pernafasan pesakit ialah 9/min dan pesakit sangat mengantuk. Apakah yang patut dilakukan oleh jururawat?

1. AMenahan dos, menilai pesakit dan memaklumkan pempreskripsi
2. BMemberikan dos dan menyemak semula kadar pernafasan esok
3. CMemberikan separuh dos
4. DMemberikan dos kerana kesakitan dilaporkan tadi

A patient taking spironolactone asks about using a salt substitute. What should the nurse explain?

1. ASalt substitutes are safe because they contain only sodium chloride
2. BSalt substitutes are fine as long as the patient drinks more water
3. CMost salt substitutes contain potassium and can raise the level too high
4. DSalt substitutes protect against the potassium loss caused by this drug

A patient's AST is about twice the ALT, both moderately raised, and the GGT is high. Which cause is most likely?

1. AAlcohol-related liver disease
2. BAcute viral hepatitis A
3. CAcute myocardial infarction
4. DGallstone blocking the bile duct

Why is it important to prevent hypothermia during and after surgery?

1. AIt makes the patient's pain disappear
2. BIt causes high blood glucose only
3. CIt makes the patient wake up too quickly and become agitated in recovery
4. DIt increases the risk of wound infection, bleeding and cardiac complications

Which action is most important in protecting a patient with severe neutropenia from infection?

1. AKeeping fresh flowers and plants in the room to help the patient's mood
2. BGiving routine intramuscular injections
3. CTaking rectal temperatures regularly
4. DStrict hand hygiene by everyone who has contact with the patient

Which exercise advice is recommended for intermittent claudication?

1. AWalking only on days when the legs feel warm and painless
2. BComplete bed rest until the leg pain has gone for at least a month
3. CStopping walking at the very first twinge of pain each time
4. DSupervised walking until pain is near maximal, then rest and repeat

A patient has been on continuous NIV via a full-face mask for two days. Which nursing measure helps prevent the most common complication?

1. ATighten the straps as far as they will go to stop any leak
2. BUse the same mask size for every patient
3. CRemove the mask for an hour each time the alarm sounds
4. DCheck mask fit and protect the bridge of the nose

Mengapakah kateterisasi sendiri berselang sering diajar selepas kecederaan saraf tunjang?

1. AIa menyingkirkan sepenuhnya semua risiko jangkitan saluran kencing
2. BIa melatih pundi kencing untuk membesar secara beransur-ansur dari semasa ke semasa
3. CIa terutamanya digunakan untuk mengukur pengeluaran air kencing dengan tepat
4. DPundi kencing mungkin tidak kosong, dan pengosongan secara tetap melindungi buah pinggang

Three days after a stroke, a patient with dysphagia on a modified diet has a temperature of 38.2 °C (100.8 °F), a respiratory rate of 24/min and crackles at the right lung base. What should the nurse do?

1. ARecord the findings and recheck them at the next routine observation
2. BEncourage more fluids by mouth to treat the fever
3. CGive paracetamol (acetaminophen) and continue the modified diet as before
4. DSuspect aspiration pneumonia, stop oral intake and escalate for review

A patient received IV morphine 20 minutes ago and the surgical consent form has not been signed. What should the nurse do?

1. ASign the form on the patient's behalf as a witness
2. BAsk the patient to sign quickly before they get sleepier
3. CAsk a relative to sign instead of the patient
4. DTell the surgeon, as the patient may not be able to consent now

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

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