ورقة عمل تحديد الأولويات والتفويض مع الإجابات

Which finding in an infant is a sign of breathing difficulty?

1. AA strong cry
2. BPink, warm hands and feet
3. CNasal flaring
4. DWet diapers every few hours

لدى مريض خثار وريدي عميق جديد، ويقول أيضًا إنه يشعر بالوحدة في الجناح. باستخدام هرم مازلو، أي حاجة تأتي أولًا؟

1. Aالحاجة إلى التقدير والاحترام
2. Bالحاجة إلى الحب والانتماء أثناء الإقامة في المستشفى
3. Cالحاجة الفيزيولوجية المتعلقة بالخثار
4. Dالحاجة إلى تحقيق الذات

In a three-level triage system, what does “urgent” mean?

1. ASerious but stable for now, and needs care soon
2. BLife-threatening and needs care immediately
3. CAlready deceased on arrival
4. DMinor, and can safely wait for several hours

A patient uses patient-controlled analgesia (PCA) after surgery. Which statement by a family member shows a need for further teaching?

1. A“The pump has limits set by the nurse so she cannot get too much at once.”
2. B“I will press the button for her while she is asleep so she stays comfortable.”
3. C“I will tell the nurse if she becomes very sleepy or hard to wake.”
4. D“Only she should press the button when she needs pain relief.”

A patient with diabetes is unresponsive and has a blood glucose of 40 mg/dL (2,2 mmol/L). What should the nurse do first?

1. APour orange juice into the patient’s mouth
2. BGive the scheduled dose of insulin
3. CWait 15 minutes and recheck the glucose
4. DGive IV dextrose or glucagon as prescribed

A nurse teaches a patient with heart failure. Which statement shows a need for further teaching?

1. A“I will take my water tablet in the morning.”
2. B“I will call if my weight goes up quickly over a day or two.”
3. C“I will weigh myself every morning after I use the toilet.”
4. D“I add extra salt to my food so it tastes better.”

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. BGive the insulin as a fast bolus to bring the potassium up
3. CIgnore the result, since potassium is always high in this condition and will correct itself
4. DStart the insulin at once, because the glucose is the bigger problem

Which assignment by the charge nurse should be changed?

1. AAn LPN/LVN is assigned to give oral medications to stable patients
2. BA nursing assistant is assigned to help several stable patients with their meals
3. CAn RN is assigned to a patient receiving a blood transfusion
4. DAn LPN/LVN is assigned to admit a new patient from the emergency department