정답이 있는 우선순위 설정과 위임 학습지

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

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

In mmHg, what is the normal range for arterial PaCO₂?

1. A22–26 mmHg
2. B35–45 mmHg
3. C80–100 mmHg
4. D7.35–7.45 mmHg

간호조무사가 네 가지 소견을 보고합니다. 간호사가 가장 먼저 확인해야 할 것은 무엇인가요?

1. A친척에게 전화하고 싶어 하는 환자
2. B아침 식사를 다 먹지 못한 환자
3. C담요를 한 장 더 달라고 하는 환자
4. D갑자기 오른팔을 움직이지 못하는 환자

Which finding is an early sign of compartment syndrome in a patient with a lower leg fracture?

1. AA strong pedal pulse with warm, pink toes and pain that settles with analgesia
2. BPain out of proportion to the injury that worsens when the toes are stretched
3. CItching under the cast during the first week after it was applied
4. DMild bruising around the fracture site on the second day

During an IV vancomycin infusion, a patient develops flushing and itching of the face and neck. What should the nurse do first?

1. ASpeed up the infusion to finish it quickly
2. BApply a warm compress to the face and neck
3. CStop or slow the infusion and inform the provider
4. DIgnore it, because flushing is always harmless and passes

A nurse teaches a patient about levothyroxine. Which statement shows a need for further teaching?

1. A“I will take it at the same time each morning.”
2. B“I will keep taking it even when I feel well.”
3. C“I will take it at breakfast with my calcium tablet.”
4. D“I will take it on an empty stomach with a glass of water.”

A patient takes lithium. Which statement shows a need for further teaching?

1. A“I will drink enough fluid every day.”
2. B“I will go for my blood tests as planned.”
3. C“I will take ibuprofen every day for my headaches.”
4. D“I will keep my daily salt intake about the same as usual.”

A patient on a cardiac monitor suddenly becomes unresponsive, and the monitor shows ventricular fibrillation. What is the priority once help has been called?

1. ADefibrillate as soon as the defibrillator is available, with CPR until then
2. BCheck the blood potassium level before any shock is considered
3. CRecord a full 12-lead ECG to confirm the rhythm before doing anything else at all
4. DGive an oral antiarrhythmic tablet and recheck the rhythm in five minutes