ورقة عمل تحديد الأولويات والتفويض مع الإجابات

Which body temperature is a fever in an adult?

1. A37,1 °C
2. B36,4 °C
3. C36,8 °C
4. D38,5 °C

What are Kussmaul respirations?

1. AShort pauses in breathing during normal sleep
2. BNoisy, high-pitched breathing caused by a blocked upper airway
3. CSlow, shallow breathing after an opioid overdose
4. DDeep, rapid breathing seen in metabolic acidosis such as DKA

In US patient-safety terms (The Joint Commission), what is a sentinel event?

1. AA routine handover between shifts
2. BA planned admission to intensive care
3. CAn unexpected event that causes death or serious harm
4. DA minor error that was noticed but caused no harm at all

After a hip replacement using a posterior approach, which statement shows a need for further teaching?

1. A“I will keep a pillow between my knees when I lie on my side in bed.”
2. B“I will cross my legs when I sit, so I am more comfortable.”
3. C“I will not bend my hip past 90 degrees.”
4. D“I will use a raised toilet seat at home.”

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

During an IV vancomycin infusion, a patient develops flushing and itching of the face and neck. What should the nurse do first?

1. AApply a warm compress to the face and neck
2. BIgnore it, because flushing is always harmless and passes
3. CStop or slow the infusion and inform the provider
4. DSpeed up the infusion to finish it quickly

Four laboratory results come back at once. Which one should the nurse report first?

1. AHemoglobin 6,5 g/dL (65 g/L) in a patient with a GI bleed
2. BGlucose 180 mg/dL after a meal in a patient with diabetes
3. CPotassium 3,4 mEq/L in a patient on a diuretic
4. DCreatinine 1,3 mg/dL in an older adult, unchanged from last week

A nurse teaches a patient to inject enoxaparin at home. Which statement shows a need for further teaching?

1. A“I will rub the area after the injection to help it absorb.”
2. B“I will inject into the fat of my abdomen, away from the navel.”
3. C“I will tell my doctor if I notice unusual bruising or bleeding.”
4. D“I will change the injection site each time.”