ورقة عمل تحديد الأولويات والتفويض مع الإجابات

Which finding should a nursing assistant report to the nurse at once?

1. AA patient whose weight is unchanged from yesterday
2. BA patient who would like tea instead of coffee
3. CA patient who wants to shower in the evening
4. DA pulse of 42/min in a patient whose usual pulse is 76/min

Which task should the registered nurse not delegate to a nursing assistant?

1. AEvaluating whether the patient understood discharge teaching
2. BWalking a stable patient up and down the corridor after lunch
3. CGiving a bed bath to a stable patient
4. DMaking an occupied bed

What should the nurse try before using physical restraints on a confused patient?

1. ARestraining all four limbs to be fully safe
2. BLess restrictive measures, such as more frequent checks or a bed alarm
3. CAsking the family to bring restraints from home
4. DUsing restraints at once and removing them later if they turn out not to be needed

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

1. AIron deficiency anemia
2. BHeparin-induced thrombocytopenia
3. CAn expected effect that needs no action
4. DVitamin K deficiency

A nasogastric tube has just been placed for feeding. What must happen before the first feed is given?

1. AThe patient is asked if the tube feels comfortable
2. BPlacement is confirmed by an approved method
3. CThe feed is started slowly to see if the patient coughs
4. DThe tube is flushed with a large volume of water

A parent calls to say their toddler has just swallowed drain cleaner. What should the nurse advise?

1. AGive a large glass of fizzy drink or milk to dilute the cleaner before calling anyone
2. BDo not make the child vomit; call poison control or emergency services now
3. CWait to see whether the child develops any symptoms first
4. DMake the child vomit straight away to bring up the chemical

Which patient with cirrhosis should the nurse see first?

1. AVomiting bright red blood, heart rate 120/min
2. BLarge ascites that is unchanged from yesterday
3. CWants to talk about stopping drinking alcohol for good
4. DLong-standing jaundice and itchy skin, asking for cream

A 2-month-old infant has a spiral fracture of the femur. The parents say the baby rolled off the sofa. What should the nurse recognize?

1. AInfants of this age often roll off furniture and break bones in this way
2. BNo further action is needed once the fracture is treated
3. CThe injury does not fit the infant’s development, so possible abuse must be reported
4. DA spiral fracture in an infant is always caused by birth trauma