정답이 있는 우선순위 설정과 위임 학습지

What is the CIWA scale used to assess?

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

What does the Braden Scale measure?

1. AThe risk of developing a pressure injury
2. BThe risk of falling during a hospital stay
3. CThe severity of alcohol withdrawal symptoms
4. DThe level of consciousness after a head injury

In Maslow’s hierarchy of needs, which level sits at the top?

1. ASafety and security
2. BLove and belonging
3. CSelf-actualization
4. DEsteem

A nurse teaches a patient with heart failure. Which statement shows a need for further teaching?

1. A“I will call if my weight goes up quickly over a day or two.”
2. B“I will take my water tablet in the morning.”
3. C“I will weigh myself every morning after I use the toilet.”
4. D“I add extra salt to my food so it tastes better.”

An older patient with dementia is restless at night and keeps trying to get out of bed. Which measure should the nurse try first?

1. AApply wrist restraints for the rest of the night
2. BGive a sedative from the as-needed list without first assessing the patient
3. CCheck for pain, thirst or a full bladder, and offer toileting
4. DRaise all four bed rails so the patient cannot climb out

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

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

A charge nurse notices that a nurse smells of alcohol and is slurring words at the start of the shift. What is the priority?

1. ALet the nurse work, but only with stable patients
2. BWait until the end of the shift and then discuss the concern with the nurse privately
3. CRemove the nurse from patient care and report it according to policy
4. DAsk the nurse to drink coffee and then start work

Two days after starting haloperidol, a patient suddenly develops painful neck twisting and the eyes roll upwards. What should the nurse anticipate?

1. AA higher dose of haloperidol to calm the patient and stop the movements quickly
2. BNo action, because the spasm is a sign of improvement
3. CPhysical restraint until the spasm passes
4. DAn anticholinergic drug, such as benztropine or procyclidine, as prescribed