Scheda di esercizi di Priorità e delega con soluzioni

Which capillary refill time is prolonged in an adult?

1. A1 second
2. B2 seconds
3. C4 seconds
4. DLess than 1 second

Which task is appropriate to delegate to a nursing assistant for an immobile but stable patient?

1. AChoosing which wound dressing to use
2. BTurning and repositioning the patient every 2 hours
3. CDeciding whether a pressure injury has got worse since yesterday
4. DPlanning the patient’s skin care

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

1. A2,0–3,0
2. B4,0–5,0
3. C6,0–7,0
4. D0,5–1,0

A patient on a nasal cannula at 6 L/min still has a low SpO₂. What should the nurse do?

1. ARemove the oxygen to see if the SpO₂ changes
2. BRecheck the SpO₂ at the next routine set of observations in four hours
3. CReport it, because a different oxygen device is likely to be needed
4. DTurn the nasal cannula up to 15 L/min

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

1. A“I will use a raised toilet seat at home.”
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 keep a pillow between my knees when I lie on my side in bed.”

A patient with type 1 diabetes has vomited since morning and cannot eat. Which action is most important?

1. AEncourage a large meal to settle the stomach
2. BCheck the blood glucose and ketones and contact the provider
3. CStop all insulin until the patient is able to eat normally again
4. DWait until tomorrow to see if the vomiting settles

A patient arrives one hour after the start of stroke symptoms. Which step must happen before a thrombolytic drug can be given?

1. AA full lipid profile to check cholesterol
2. BA brain scan to rule out bleeding
3. CAn echocardiogram to look for clots
4. DA swallow test with a cup of water

Durante un'alimentazione enterale continua con sondino, un paziente comincia all'improvviso a tossire, ha affanno e la SpO₂ scende. Qual è la prima azione dell'infermiere?

1. ALavare il sondino con 50 mL di acqua, poi continuare l'alimentazione come prima
2. BSospendere l'alimentazione, mettere il paziente seduto e valutare la respirazione
3. CAumentare la velocità dell'alimentazione perché finisca prima
4. DMettere il paziente disteso perché riposi