정답이 있는 우선순위 설정과 위임 학습지

A patient has a Glasgow Coma Scale score of 8. What is the main concern?

1. AThe patient may not be able to protect the airway
2. BThe patient is fully alert and oriented
3. CThe patient only has a mild headache
4. DThe patient can safely eat and drink without help

Which task is appropriate to delegate to a nursing assistant?

1. AFeeding a patient with newly diagnosed dysphagia after a stroke
2. BAssessing a pressure injury on the sacrum
3. CFeeding a stable patient who has no swallowing problems
4. DGiving a stable patient their oral medications

Which symptoms are classic signs of digoxin toxicity?

1. AA rash, high fever and swollen lymph nodes in the neck
2. BNausea, poor appetite and yellow-green visual halos
3. CHair loss and weight gain
4. DHigh blood sugar and increased thirst

A patient has a serum potassium of 2.9 mEq/L. Which finding should the nurse expect?

1. AFlushed, warm skin and a slow heart rate
2. BA rise in urine output and thirst only
3. CTall, peaked T waves and muscle twitching
4. DMuscle weakness and U waves on the ECG

A patient taking warfarin has an INR of 5.2 and no signs of bleeding. What should the nurse do?

1. AHold the warfarin dose and inform the provider
2. BEncourage the patient to take aspirin for pain
3. CGive a double dose to correct the result
4. DGive the usual dose and recheck the INR next month

A patient with angina is taught to use sublingual nitroglycerin (GTN). Which statement shows a need for further teaching?

1. A“I will carry the tablets with me when I go out.”
2. B“If the pain has not eased as my action plan says, I will call emergency services.”
3. C“I will sit or lie down when I take a tablet.”
4. D“I will take five tablets one after the other before I call for help.”

A patient with known abdominal aortic aneurysm suddenly has severe back pain, a pulsing mass in the abdomen and a falling blood pressure. What should the nurse do?

1. AEncourage the patient to walk to ease the back pain
2. BCall for emergency help at once and prepare for urgent surgery
3. CGive an oral analgesic and reassess the patient in about one hour
4. DPalpate the mass firmly to check its size and spread

A patient has a chest drain for a pneumothorax. The nurse sees constant bubbling in the water-seal chamber. What does this most likely mean?

1. AThe lung has fully re-expanded, so the drain is ready to come out
2. BThe drain is working normally and no action is needed
3. CAn air leak in the patient or the system that needs checking
4. DThe suction is set too low and needs to be turned up