Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

Kuris pacientas yra stabiliausias?

1. APacientas praėjus dviem dienoms po kelio operacijos, skausmas 3/10, normalūs gyvybiniai rodikliai
2. BPacientas su nauju krūtinės skausmu
3. CPacientas, kurio kraujospūdis nukrito nuo 132/80 iki 90/56 mmHg
4. DPacientas, kuris naujai susimaišė

Why may a full-thickness burn feel painless at its center?

1. AThe patient has been given too much fluid
2. BThe burn only affects the thin surface layer of the skin
3. CThe burn has already fully healed
4. DThe nerve endings in the skin have been destroyed

After chemotherapy, a patient has a very low neutrophil count. Which risk is the nursing priority?

1. AHypertension
2. BDehydration
3. CInfection
4. DBleeding

A nurse cannot read part of a medication order. What should the nurse do?

1. ASkip the drug and not tell anyone until the next ward round
2. BAsk another nurse to guess what the order most likely says, then give it
3. CContact the prescriber to clarify the order before giving the drug
4. DGive the usual dose of the drug the nurse thinks was meant

A pregnant nurse is on the unit. Which patient should the charge nurse avoid assigning to her?

1. AA patient with type 2 diabetes who needs insulin teaching before discharge
2. BA patient with a fractured wrist
3. CA patient after a hip replacement
4. DA patient with a sealed radioactive implant for cervical cancer

A patient has a reddened area on the sacrum that does not blanch when pressed. What is the priority action?

1. AKeep the patient lying on the back to protect the area
2. BMassage the area firmly to improve the blood flow to the skin
3. CRelieve pressure on the area by changing position regularly
4. DApply a heat pad to the area to increase circulation

Kurį pacientą slaugytojas turėtų pirmiausia eskaluoti skubaus reagavimo komandai?

1. APacientą, sergantį celiulitu, kurio temperatūra 38,1 °C, o kiti gyvybiniai rodikliai normalūs
2. BPacientą, sergantį šlapimo takų infekcija, kuris naujai susimaišė, kvėpavimo dažnis 26/min, o sistolinis kraujospūdis 94 mmHg
3. CPacientą, kuriam žinoma hipertenzija, kurio kraujospūdis 152/94 mmHg ir kuris jaučiasi gerai
4. DPacientą po kelio operacijos su 6/10 skausmu ir normaliais gyvybiniais rodikliais

A provider asks a nurse to perform a procedure that is outside the nurse’s scope of practice. What should the nurse do?

1. ADo it, because the provider gave the instruction
2. BAsk a nursing assistant to do it instead
3. CDecline, explain why and suggest who can safely do it
4. DDo it just this once and promise the provider not to do it again