Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

Seorang jururawat mendelegasikan pengukuran glukosa darah kepada pembantu yang terlatih tetapi tidak pernah meminta keputusannya. Hak pendelegasian manakah yang tiada?

1. AKeadaan yang betul
2. BOrang yang betul untuk tugas itu
3. CPenyeliaan dan penilaian yang betul
4. DTugas yang betul untuk tetapan itu

A patient with diabetic ketoacidosis is about to start an IV insulin infusion. The serum potassium is 3.0 mEq/L. What should the nurse do?

1. AReport the result before starting, because insulin will push potassium even lower
2. BStart the insulin at once, because the glucose is the bigger problem
3. CIgnore the result, since potassium is always high in this condition and will correct itself
4. DGive the insulin as a fast bolus to bring the potassium up

Mengapakah ubat cecair oral diberikan dengan picagari oral atau enteral dan bukannya picagari IV piawai?

1. ATiada sebab keselamatan; ia hanya tradisi
2. BPicagari oral menyukat dos intravena dengan lebih tepat
3. CPicagari IV tidak dapat menyukat isi padu kecil cecair oral dengan tepat
4. DPicagari oral tidak muat pada talian IV, mencegah kesilapan laluan yang salah

A nurse has weeping dermatitis on both hands. What is the most appropriate action?

1. ACover the lesions with a waterproof bandage and keep working with patients as usual
2. BAvoid direct patient care and handling of equipment until it heals, and see occupational health
3. CContinue care as usual and wear one pair of gloves
4. DUse extra alcohol hand rub on the lesions

In the third trimester of pregnancy, a woman's alkaline phosphatase (ALP) is about twice the usual adult range, and the other liver tests are normal. What is the best interpretation?

1. AA sign of new bone cancer
2. BA sign of acute viral hepatitis
3. CA normal rise from placental ALP
4. DA sign of blocked bile ducts

Two days after bowel surgery, a patient with nasogastric suction has a distended abdomen, absent bowel sounds and muscle weakness. The potassium is 2.8 mEq/L. Which interpretation is best?

1. AHyperkalemia from tissue damage is causing the bowel to stop
2. BThe low potassium is due to the patient drinking too much water
3. CHypokalemia from gastric losses is contributing to paralytic ileus
4. DThe potassium is normal for the second day after surgery

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

1. ABreathing function, such as forced vital capacity
2. BVisual acuity
3. CBlood glucose, measured once a day before breakfast
4. DWeekly weight

A patient suddenly develops a severe "worst ever" headache that reached full intensity within seconds, followed by vomiting and neck stiffness. What should be suspected?

1. AMigraine with aura in a known migraine sufferer
2. BSinusitis
3. CSubarachnoid haemorrhage
4. DTension headache

Tekanan darah seorang pesakit ialah 200/125 mmHg dengan kekeliruan baharu dan penglihatan kabur. Bagaimanakah ia biasanya diturunkan?

1. ASecepat mungkin, kepada nilai normal dalam masa beberapa minit
2. BTidak langsung, kerana otak kini bergantung pada tekanan yang tinggi
3. CDengan ubat IV yang dititrasi, sehingga kira-kira 25% dalam jam pertama
4. DDengan tablet oral baharu dan semakan dalam seminggu

A heavy smoker is having surgery tomorrow and asks whether stopping smoking now is pointless. Which reply is most accurate?

1. AStopping now will make the operation more dangerous
2. BSmoking before surgery protects the lungs from the anaesthetic gases
3. CIt is pointless unless they stopped smoking at least a year ago
4. DStopping even today lowers carbon monoxide levels before surgery

A bladder scan straight after voiding shows 450 mL of urine still in the bladder. What does this show?

1. AThe kidneys are making too little urine
2. BThe bladder is not emptying properly
3. CThe patient has drunk too little fluid
4. DThe patient is passing urine normally

A nurse teaches a woman with recurrent UTIs. Which statement shows a need for further teaching?

1. A"I will drink enough fluids during the day."
2. B"I will wipe from front to back."
3. C"I will hold my urine for as long as I can."
4. D"I will pass urine soon after sex."

A dying patient can no longer drink. Which mouth care is most appropriate?

1. ABrushing hard with a stiff toothbrush twice a day
2. BFrequent, gentle moistening of the mouth and lips
3. CNo mouth care, to avoid disturbing the patient
4. DLemon and glycerine swabs every hour to stimulate saliva

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

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