ورقة عمل تحديد الأولويات والتفويض مع الإجابات

What is the range of possible scores on the Glasgow Coma Scale?

1. A0 to 15
2. B3 to 15
3. C1 to 20
4. D0 to 10

المهمة التي تتطلب تقييمًا أو حكمًا تمريضيًا أو تقويمًا ينبغي أن:

1. Aتُفوَّض إلى أكثر مساعدي التمريض خبرة
2. Bتُعطى لأسرة المريض
3. Cتُفوَّض دائمًا إلى ممرضة عملية (LPN/LVN)
4. Dتؤديها الممرضة المسجلة

Which task is appropriate to delegate to a nursing assistant?

1. AFeeding a stable patient who has no swallowing problems
2. BFeeding a patient with newly diagnosed dysphagia after a stroke
3. CAssessing a pressure injury on the sacrum
4. DGiving a stable patient their oral medications

Which postoperative patient should the nurse see first?

1. AAsking when the urinary catheter will be removed
2. BDressing soaked with bright red blood and a heart rate rising to 118/min
3. CPain of 4/10 one hour after an oral analgesic
4. DWants help with washing her hair before her visitors arrive this afternoon

After a hip replacement, a patient has sudden severe hip pain, and the operated leg looks shorter and turned. What should the nurse suspect?

1. AA urinary tract infection
2. BA pressure injury on the heel
3. CDislocation of the new hip
4. DNormal pain after surgery

Which action helps prevent a catheter-associated urinary tract infection?

1. ALeaving the catheter in place longer than needed
2. BKeeping the drainage bag below the level of the bladder
3. CRaising the drainage bag above the bladder when walking
4. DDisconnecting the bag every shift to empty it

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

A patient has peripheral arterial disease with a non-healing ulcer on the toe. Which advice about leg position is correct?

1. ASit with the legs crossed to improve blood flow
2. BKeep the legs raised above the heart as much as possible
3. CWrap the legs tightly with compression bandages
4. DKeep the legs level or slightly lowered, not raised