ورقة عمل تحديد الأولويات والتفويض مع الإجابات

What is the CIWA scale used to assess?

1. AThe severity of alcohol withdrawal
2. BThe severity of a newborn’s jaundice
3. CThe risk of a pressure injury
4. DThe depth of a burn wound

Which value is the usual target INR for a patient taking warfarin for atrial fibrillation?

1. A6,0–7,0
2. B4,0–5,0
3. C2,0–3,0
4. D0,5–1,0

Which three things does START triage check in a non-walking adult?

1. ARespirations, perfusion and mental status
2. BPulse, blood pressure and body temperature
3. CAirway, blood glucose and pupils
4. DPain score, mobility and age

Five days after starting heparin, a patient’s platelet count has fallen by more than half. What should the nurse suspect?

1. AVitamin K deficiency
2. BHeparin-induced thrombocytopenia
3. CIron deficiency anemia
4. DAn expected effect that needs no action

A patient with asthma has two inhalers: a corticosteroid and salbutamol (albuterol). Which statement shows a need for further teaching?

1. A“I will carry my salbutamol inhaler with me.”
2. B“I will use my steroid inhaler every day, even when I feel well.”
3. C“I will use my steroid inhaler when I have a sudden attack.”
4. D“I will rinse my mouth after using the steroid inhaler.”

A patient at 35 weeks of pregnancy with high blood pressure calls the clinic. Which symptom needs urgent assessment?

1. AA severe headache with blurred vision
2. BNeeding to pass urine more often
3. CBackache after a long walk
4. DMild ankle swelling at the end of the day

A visitor on the ward becomes threatening and shows a knife. What is the nurse’s priority?

1. AArgue with the visitor to persuade them to leave
2. BTry to take the knife away from the visitor straight away before anyone is hurt
3. CIgnore the visitor and carry on with patient care
4. DMove away to safety, keep others away and call security or the police

After cardiac surgery, a patient becomes hypotensive with distended neck veins and muffled heart sounds, and chest drain output has suddenly stopped. What should the nurse suspect?

1. ACardiac tamponade
2. BA blocked urinary catheter
3. CLeft-sided heart failure
4. DHypovolemic shock from dehydration