ورقة عمل تحديد الأولويات والتفويض مع الإجابات

Which finding meets the usual definition of orthostatic hypotension?

1. AHeart rate falls by 5/min after lying down
2. BBlood pressure is the same lying and standing
3. CSystolic pressure falls by 20 mmHg or more within 3 minutes of standing
4. DSystolic pressure rises by 20 mmHg or more within 3 minutes of standing up

Why may a full-thickness burn feel painless at its center?

1. AThe nerve endings in the skin have been destroyed
2. BThe burn has already fully healed
3. CThe burn only affects the thin surface layer of the skin
4. DThe patient has been given too much fluid

Which phrase in a question usually signals a priority question?

1. A“Which bone is found in the forearm?”
2. B“Which statement describes this drug’s class?”
3. C“Which term means inflammation of the liver?”
4. D“Which action should the nurse take first?”

Which action by a nursing assistant needs the nurse to step in?

1. ACleaning hands before entering the room
2. BPutting the call light within the patient’s reach
3. CTaking an oral temperature just after the patient drank cold water
4. DLowering the bed to its lowest position and locking the wheels after care

Straight after birth, what is the first priority for a healthy-looking newborn?

1. AWeigh and measure the baby on the scale
2. BDry and warm the baby while checking that it is breathing
3. CGive the vitamin K injection before anything else is done
4. DGive the first bath to remove the blood and vernix

A patient with schizophrenia says voices are telling him to hurt his roommate. What is the priority?

1. AIgnore the comment, because voices are part of his illness
2. BKeep everyone safe and tell the team, as the risk of harm is high
3. CAsk the roommate to stay in the room with him and help calm him down
4. DTell him the voices are not real and leave him alone

Using ESI, a stable adult with abdominal pain will need blood tests and a CT scan, but has a heart rate of 130/min. Which statement is correct?

1. AVital signs never change the ESI level
2. BThe patient is level 4 because the blood tests and the scan count as one resource
3. CThe nurse should consider level 2 because of the danger-zone vital sign
4. DThe patient is level 5 because the pain is not severe

A patient who is 7 weeks pregnant has one-sided lower abdominal pain, pain in the shoulder tip, a heart rate of 120/min and a blood pressure of 88/54 mmHg. What is most likely?

1. AA urinary tract infection
2. BA normal early pregnancy
3. CA ruptured ectopic pregnancy
4. DSevere morning sickness