정답이 있는 우선순위 설정과 위임 학습지

Which value is the usual target INR for a patient taking warfarin for atrial fibrillation?

1. A4.0–5.0
2. B6.0–7.0
3. C2.0–3.0
4. D0.5–1.0

다수 사상자 트리아지에서 검은색 표지는 무엇을 뜻하나요?

1. A오염되어 어떤 치료 전에도 완전한 제염이 필요함
2. B몇 시간 기다릴 수 있는 경상
3. C사망했거나, 가용한 자원으로는 생존 가능성이 낮음
4. D모든 피해자 중 치료 우선순위가 가장 높음

Who is responsible for developing the nursing plan of care?

1. AThe ward clerk
2. BThe LPN/LVN alone
3. CThe nursing assistant
4. DThe registered nurse

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

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

An anxious patient is breathing very fast and has tingling fingers. The blood gas shows pH 7.51 and PaCO₂ 29 mmHg (3.9 kPa). What should the nurse do first?

1. AGive oxygen at the highest flow and leave the room
2. BEncourage the patient to breathe even faster
3. CStay with the patient and coach slow, calm breathing
4. DGive IV sodium bicarbonate as soon as it can be found

A patient on a continuous IV heparin infusion has new black, tarry stools and an aPTT well above the target range. What should the nurse do first?

1. AGive a dose of vitamin K by mouth
2. BOffer an iron-rich meal to replace the lost blood
3. CCheck the pump rate and leave the infusion running
4. DStop the heparin infusion and inform the provider

After a cervical spinal cord injury, a patient has a blood pressure of 80/50 mmHg, a heart rate of 48/min and warm, dry skin. What is most likely?

1. ANeurogenic shock
2. BSeptic shock
3. CCardiac tamponade
4. DHypovolemic shock

After a head injury, a patient has clear fluid dripping from the nose. Which action should the nurse avoid?

1. AChecking the fluid for glucose or a halo sign on gauze
2. BPlacing a loose gauze under the nose
3. CInforming the provider about the drainage
4. DInserting a tube or suction catheter through the nose