정답이 있는 우선순위 설정과 위임 학습지

Which capillary refill time is prolonged in an adult?

1. A4 seconds
2. B2 seconds
3. C1 second
4. DLess than 1 second

Which serum potassium result should the nurse report to the provider promptly?

1. A4.2 mEq/L (4.2 mmol/L)
2. B4.9 mEq/L (4.9 mmol/L)
3. C3.8 mEq/L (3.8 mmol/L)
4. D6.4 mEq/L (6.4 mmol/L)

매슬로의 위계에서 생리적 욕구 바로 다음 단계는 무엇인가요?

1. A자아실현
2. B안전과 안정
3. C존중과 인정
4. D사랑과 소속

안정된 성인이 복통이 있고 활력징후는 정상입니다. 혈액 검사와 CT 촬영이 필요합니다. 어느 ESI 단계에 해당하나요?

1. A5단계
2. B1단계
3. C4단계
4. D3단계

A patient with a spinal cord injury at T4 suddenly has a severe headache, flushing above the injury and a blood pressure of 200/110 mmHg. What does the nurse do first?

1. ASit the patient upright with the legs lowered
2. BGive a warm drink and recheck the blood pressure in an hour
3. CLay the patient flat with the legs raised
4. DApply extra blankets to keep the patient warm and calm

A patient’s urinary catheter has drained no urine for two hours, and the lower abdomen is swollen. What should the nurse do first?

1. ACheck the tubing for kinks or obstruction
2. BGive a prescribed diuretic straight away
3. CRemove the catheter and wait for the patient to void
4. DEncourage the patient to drink more water

On a cardiac step-down unit, which patient should the nurse assess first?

1. AHeart failure, weight up 0.5 kg since yesterday, no breathlessness at rest
2. BSix hours after a coronary stent, new chest pain with ST elevation on the monitor
3. CDay 2 after a pacemaker insertion, asking when the wound dressing will be changed
4. DAtrial fibrillation on warfarin with an INR of 2.6 this morning

During JumpSTART triage, a child is not breathing after the airway is opened but has a palpable pulse. What is the next step?

1. ATag the child green and return to them after the others
2. BStart full CPR on the child and stay with them until more help arrives
3. CGive five rescue breaths; if breathing starts, tag the child red
4. DTag the child black at once and move on to the next victim