정답이 있는 우선순위 설정과 위임 학습지

일반적으로 다른 것보다 먼저 다루는 문제 유형은 무엇인가요?

1. A이전 간호 계획에 올라 있는 문제
2. B퇴원을 위한 학습 요구
3. C환자가 지금 겪고 있는 실제 문제
4. D나중에 생길 수 있는 위험 문제

Which serum creatinine result suggests reduced kidney function in an adult?

1. A0.7 mg/dL (about 60 µmol/L)
2. B1.0 mg/dL (about 90 µmol/L)
3. C3.5 mg/dL (about 310 µmol/L)
4. D0.8 mg/dL (about 70 µmol/L)

Which white blood cell count suggests an infection or inflammation?

1. A8,200/mm³ (8.2 × 10⁹/L)
2. B18,000/mm³ (18 × 10⁹/L)
3. C6,500/mm³ (6.5 × 10⁹/L)
4. D7,000/mm³ (7 × 10⁹/L)

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. AOffer an iron-rich meal to replace the lost blood
2. BStop the heparin infusion and inform the provider
3. CGive a dose of vitamin K by mouth
4. DCheck the pump rate and leave the infusion running

A parent of a child with influenza talks with the nurse. Which statement shows a need for further teaching?

1. A“I will give my child aspirin to bring the fever down.”
2. B“I will call if my child has trouble breathing.”
3. C“I will give my child plenty of fluids.”
4. D“I will keep my child home from school and away from others while unwell.”

휴게실에서 식사하던 성인 환자가 갑자기 목을 움켜쥐고 말도, 숨도, 기침도 하지 못합니다. 간호사가 가장 먼저 해야 할 일은 무엇인가요?

1. A환자가 기침으로 뱉는지 지켜본다
2. B눈에 보이지 않는 입속을 손가락으로 쓸어낸다
3. C음식을 넘기도록 물을 한 잔 준다
4. D도움을 요청하고 등 두드리기와 복부 밀어내기를 한다

Two hours after a femoral cardiac catheterization, the nurse sees blood spreading from the puncture site. What is the first action?

1. ARaise the head of the bed so the patient can sit up
2. BApply firm, direct pressure just above the puncture site
3. CRemove the dressing and leave the site open to the air
4. DAsk the patient to bend the leg at the hip to stop the bleeding

A patient in hypovolemic shock is receiving IV fluids. Which finding best shows that the treatment is working?

1. AUrine output at least 0.5 mL/kg/h and clearer thinking
2. BNew crackles at both lung bases
3. CCooler, paler skin on the arms and legs
4. DA heart rate that keeps rising after each bag of fluid