Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Empat jam selepas pembedahan tiroid, dapatan pesakit manakah yang patut ditindaki dahulu oleh jururawat?

1. APermintaan untuk duduk untuk minum
2. BKesakitan pada hirisan 4/10
3. CSedikit saliran serus kelihatan pada pembalut leher
4. DSuara yang semakin serak, dengan pernafasan bising yang baharu

During surgery under general anesthesia, a patient develops rising end-tidal carbon dioxide, muscle rigidity and a rapidly increasing temperature. Which drug should the nurse anticipate?

1. AFlumazenil
2. BAtropine
3. CDantrolene
4. DNaloxone

An alcohol-based skin prep has been used before surgery with electrosurgery. What must happen before the drapes are placed?

1. AThe prep must be wiped off with saline
2. BThe prep must be fully dry and any pooled liquid removed
3. CThe prep must be covered with the drapes while it is still wet
4. DThe prep must be warmed with a hair dryer

A patient with pneumonia has low blood pressure and a raised serum lactate. What does the raised lactate suggest?

1. AA normal response to having a fever
2. BMild dehydration from poor intake, with no further concern
3. CRecovery from the infection is beginning
4. DPoor tissue perfusion, a sign of sepsis-related shock

In the US, when is a pregnant woman without known risk factors usually screened for gestational diabetes?

1. AAt about 24–28 weeks of pregnancy
2. BAt about 6–8 weeks of pregnancy
3. CAt about 38–40 weeks of pregnancy
4. DOnly after the baby is born

Seorang pesakit dengan kiraan platelet 35 × 10³/µL ditetapkan suntikan intramuskular. Apakah yang patut dilakukan oleh jururawat?

1. ABeri suntikan seperti yang ditetapkan dan urut tapak dengan kuat
2. BBeri suntikan dengan jarum yang lebih panjang
3. CBeri suntikan dan letakkan pek panas
4. DTanya pemreskripsi sama ada laluan lain boleh digunakan

During a vesicant chemotherapy infusion, the patient reports burning and swelling at the cannula site. What should the nurse do first?

1. AFlush the cannula hard with saline
2. BStop the infusion straight away and follow the extravasation protocol
3. CApply a warm pack and continue the infusion
4. DIncrease the rate so that the infusion finishes as quickly as possible

A patient due a blood transfusion is not wearing an identity band. What should the nurse do?

1. ACheck the name on the bed and proceed
2. BNot start until a correct identity band is in place and identity is confirmed
3. CAsk another patient to confirm who the patient is
4. DAsk the patient to state their name and date of birth, then start straight away

A patient with COPD uses an inhaled corticosteroid combination inhaler. Which risk should the nurse be aware of?

1. AHearing loss after every dose
2. BA sharp drop in potassium after each dose
3. CAn increased risk of pneumonia
4. DAn increased risk of high blood pressure crises

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

A patient with atrial fibrillation has had an ischaemic stroke. Which long-term medicine type most reduces the risk of another stroke?

1. AA beta-agonist inhaler
2. BAn oral anticoagulant
3. CA proton pump inhibitor
4. DA loop diuretic

Seorang pesakit strok dengan kelemahan sebelah kanan sedia dipindahkan dari katil ke kerusi. Pendekatan manakah yang paling selamat?

1. AMeletakkan kerusi di sebelah kiri dan berputar ke arahnya
2. BMeletakkan kerusi di sebelah kanan dan mengangkat pada lengan yang lemah
3. CMeminta pesakit berdiri seorang diri dan berjalan ke kerusi
4. DMenarik pesakit bangun pada bahu dan pergelangan tangan kanan

Langkah manakah yang membantu mencegah sindrom lisis tumor pada pesakit berisiko tinggi?

1. ASekatan cecair dengan tablet kalium
2. BMenghentikan semua cecair IV dan oral semasa kemoterapi
3. CSuplemen kalsium dan fosfat setiap hari
4. DHidrasi IV dengan alopurinol atau rasburikase

After a coughing fit, the external mark on a patient's nasogastric tube has moved 10 cm. Feed is due. What should the nurse do?

1. AGive the medicines only and save the feed for later
2. BPush the tube back to the original mark and start the feed
3. CStart the feed at a slow rate and watch for coughing
4. DDo not use the tube until its position is confirmed by policy