정답이 있는 우선순위 설정과 위임 학습지

Which pain scale is designed for infants and young children who cannot describe their pain?

1. AThe Braden Scale
2. BThe Morse Fall Scale
3. CThe FLACC scale
4. DThe Glasgow Coma Scale

다수 사상자 트리아지에서 초록색 표지는 보통 어느 범주를 나타내나요?

1. A즉시: 바로 치료가 필요함
2. B경상: “걸어 다니는 부상자”
3. C사망 또는 기대 불가
4. D지연: 심각하지만 현재는 안정적인 부상

Which patient usually fits ESI level 5?

1. AA stable adult who only needs a repeat prescription
2. BA stable adult who needs blood tests and an X-ray of the chest
3. CAn adult with chest pain suggesting a heart attack
4. DAn adult in cardiac arrest

A patient’s peripheral IV site is swollen, pale and cool, and the infusion has slowed. What should the nurse do first?

1. AStop the infusion and remove the cannula
2. BFlush the cannula hard to clear the blockage
3. CApply a tight bandage over the site to reduce swelling
4. DIncrease the infusion rate to overcome the resistance

A patient on hemodialysis has an arteriovenous fistula in the left arm. Which instruction should the nurse give the nursing assistant?

1. AKeep the left arm wrapped tightly in a bandage at night
2. BDo not measure blood pressure on the left arm
3. CMeasure blood pressure on the left arm only, every 4 hours
4. DHelp the patient carry shopping bags on the left arm

A conscious patient with hypoglycemia drank juice 15 minutes ago. The glucose is now 62 mg/dL (3.4 mmol/L). What should the nurse do next?

1. ARecord the result and recheck the glucose at the usual time before the evening meal
2. BWait another hour, because juice can take a long time to work
3. CGive another serving of fast-acting carbohydrate and recheck in 15 minutes
4. DGive the next scheduled dose of rapid-acting insulin with the meal

A patient with septic shock remains hypotensive, with a mean arterial pressure of 58 mmHg, after adequate IV fluids. What should the nurse anticipate?

1. AA vasopressor, such as norepinephrine, to raise the pressure
2. BA loop diuretic to remove the extra fluid that has been given
3. CAn oral fluid challenge with a sports drink
4. DA beta-blocker to slow the heart rate

A patient who is 7 weeks pregnant has one-sided lower abdominal pain, pain in the shoulder tip, a heart rate of 120/min and a blood pressure of 88/54 mmHg. What is most likely?

1. AA normal early pregnancy
2. BA urinary tract infection
3. CA ruptured ectopic pregnancy
4. DSevere morning sickness