정답이 있는 우선순위 설정과 위임 학습지

기도 문제인 소견은 무엇인가요?

1. A흡기 때 양쪽 폐 하부에서 들리는 미세한 수포음
2. B10점 만점에 8점으로 평가된 복통
3. C쉰 목소리와 함께 혀와 입술이 붓는 것
4. D약하고 가는 요골 맥박

다수 사상자 트리아지에서 초록색 표지는 보통 어느 범주를 나타내나요?

1. A경상: “걸어 다니는 부상자”
2. B지연: 심각하지만 현재는 안정적인 부상
3. C즉시: 바로 치료가 필요함
4. D사망 또는 기대 불가

Which phrase in a question usually signals a priority question?

1. A“Which action should the nurse take first?”
2. B“Which statement describes this drug’s class?”
3. C“Which term means inflammation of the liver?”
4. D“Which bone is found in the forearm?”

A patient is receiving continuous tube feeds. Which action best reduces the risk of aspiration?

1. AIncrease the feed rate so the stomach empties sooner
2. BLay the patient flat for an hour after each bag is hung
3. CTurn the feed off only while the patient is asleep at night
4. DKeep the head of the bed raised to at least 30 degrees

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. BHelp the patient carry shopping bags on the left arm
3. CDo not measure blood pressure on the left arm
4. DMeasure blood pressure on the left arm only, every 4 hours

A patient taking clozapine reports a sore throat and fever. What is the priority action?

1. AOffer throat lozenges and continue the usual dose
2. BIncrease the dose because the symptoms suggest a relapse
3. CAdvise the patient to gargle with warm salt water and rest in bed
4. DHold the dose and report so the white cell count can be checked

A visitor on the ward becomes threatening and shows a knife. What is the nurse’s priority?

1. AIgnore the visitor and carry on with patient care
2. BMove away to safety, keep others away and call security or the police
3. CTry to take the knife away from the visitor straight away before anyone is hurt
4. DArgue with the visitor to persuade them to leave

Which patient finding after a total knee replacement needs the nurse’s action first?

1. ASudden calf pain and swelling in the operated leg, with new breathlessness
2. BA small amount of dried blood on the dressing
3. CPain of 4/10 when the physiotherapist bends the knee during the morning session
4. DAsks for an ice pack to help with swelling around the knee