Pemberian Keutamaan & Delegasi Gaya NCLEX: pek ulang kaji kilat

A patient with a head injury is being monitored. Which set of findings suggests rising intracranial pressure?

1. ANormal blood pressure, normal pulse and clear speech
2. BLow temperature, fast breathing and a strong appetite
3. CRising systolic pressure, slow pulse and irregular breathing
4. DFalling blood pressure, a fast pulse and warm, flushed dry skin

Seorang pembantu jururawat mengukur tanda vital 15 minit selepas dos pertama morfin pesakit. Mereka melaporkan kadar pernafasan 10/min dan berkata pesakit sukar dikejutkan. Apakah yang patut dilakukan oleh jururawat?

1. AMenelefon pembekal penjagaan untuk arahan sebelum pergi melihat pesakit
2. BMeminta pembantu memeriksa semula kadar pernafasan dalam 15 minit dan melapor semula
3. CMendokumenkan dapatan dan memberitahu pembekal penjagaan pada pusingan berjadual seterusnya
4. DPergi serta-merta, kejutkan pesakit, sokong pernafasan dan sediakan nalokson mengikut arahan

Which part of a sterile surgical gown is considered sterile once it is on?

1. AOnly the back of the gown, which nobody touches
2. BThe front from chest to the level of the sterile field, and the sleeves
3. CThe whole gown, including the back, the collar and the area below the waist
4. DThe front from the neck down to the knees

A patient’s white cell differential shows a raised eosinophil count. Which cause is most consistent with this finding?

1. AAn allergic reaction or a parasitic infection
2. BA viral infection such as a cold
3. CBone marrow suppression from chemotherapy
4. DAn acute bacterial infection

When should the nurse check the glucose before giving a mealtime dose of rapid-acting insulin (such as lispro)?

1. AAt bedtime only, then giving the mealtime insulin overnight
2. BOnly once a day, then giving the same dose before every meal
3. CTwo hours after the meal, then giving the insulin dose
4. DJust before the meal, giving insulin when the food is ready

Seorang pesakit ketoasidosis diabetes menerima infusi insulin IV. Nilai makmal manakah yang mesti dipantau dengan sangat rapi?

1. ANatrium, kerana insulin menyebabkan buah pinggang merembeskannya dalam jumlah yang sangat besar
2. BAlbumin, kerana insulin menyebabkan hati berhenti menghasilkannya
3. CKalium, kerana insulin memindahkannya ke dalam sel dan ia boleh jatuh dengan pantas
4. DHemoglobin, kerana insulin memecahkan sel darah merah

A nurse finds a patient lying on the floor beside the bed. What should be done first?

1. ACheck the patient for injuries before moving them
2. BLift the patient straight back into bed so they are comfortable
3. CComplete the incident report form
4. DPhone the patient's family

Pesakit yang menerima pemakanan tiub enteral selepas tempoh kebuluran yang lama mengalami fosfat rendah, kalium rendah dan aritmia. Apakah yang paling mungkin?

1. AKetoasidosis diabetes
2. BSindrom lambakan (dumping)
3. CSindrom pemakanan semula (refeeding)
4. DHipertiroidisme

Why is a shock for cardioversion synchronised with the QRS complex?

1. ATo avoid delivering the shock during the T wave
2. BTo allow the use of a lower battery charge
3. CTo keep the pads from burning the skin
4. DTo make the shock less painful for the patient

Seorang pesakit asma mempunyai sejarah mengi selepas mengambil aspirin. Ibuprofen dipreskripsikan untuk kesakitan pasca-operasi. Apakah yang patut dilakukan oleh jururawat?

1. AMemberikannya, kerana ibuprofen tidak berkaitan dengan aspirin
2. BMenahannya dan meminta alternatif
3. CMemberikannya bersama inhaler pelega pada masa yang sama
4. DMemberikannya hanya jika skor kesakitan melebihi 8/10

When a patient sticks out their tongue, it points to the right. Which nerve is affected?

1. AThe left trigeminal nerve (V)
2. BThe right hypoglossal nerve (XII)
3. CThe right facial nerve (VII)
4. DThe left hypoglossal nerve (XII)

A patient who has taken prednisolone daily for years is vomiting and cannot keep tablets down. What should the nurse do?

1. AGive the tablets again after every vomit
2. BGive the next dose with a glass of milk
3. COmit the steroid until the vomiting stops
4. DEscalate urgently for steroid by injection

Mengapakah penting apabila pesakit yang menggunakan opioid menjadi lebih tersedasi?

1. ASedasi yang meningkat biasanya mendahului tekanan pernafasan
2. BSedasi ialah kesan yang tidak berbahaya dan dijangka bagi semua opioid
3. CSedasi bermakna dos yang lebih tinggi kini diperlukan
4. DSedasi bermakna kesakitan kini terkawal sepenuhnya dan dengan selamat

A patient with advanced cancer who has capacity decides to stop chemotherapy. The family insists that treatment must continue. What should the nurse do?

1. ASupport the patient's decision and help the team talk with the family
2. BAsk the family to sign a new consent form
3. CTell the patient that stopping is not allowed
4. DContinue treatment because the family has asked for it