Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

To which patients do standard precautions apply?

1. AOnly patients with a confirmed infection on a lab test
2. BOnly patients in intensive care
3. COnly patients with an open wound
4. DAll patients, whether or not an infection is known

What are Kussmaul respirations?

1. ASlow, shallow breathing after an opioid overdose
2. BShort pauses in breathing during normal sleep
3. CDeep, rapid breathing seen in metabolic acidosis such as DKA
4. DNoisy, high-pitched breathing caused by a blocked upper airway

For a patient who does not take an anticoagulant, which INR is normal?

1. A6,0
2. B4,0
3. C2,5
4. D1,0

On a pediatric unit, which child does the nurse assess first?

1. AA child with asthma who is now quiet with very little air movement
2. BA child with a temperature of 38,2 °C after vaccination
3. CA child with croup who has a barking cough but no stridor at rest
4. DA child in a new arm cast with pink, warm fingers and pain of 5/10

A patient has a blood pressure of 210/120 mmHg. Which finding would make this a hypertensive emergency?

1. ANew chest pain or confusion suggesting organ damage
2. BMild anxiety about the high reading on the monitor
3. CA history of high blood pressure for ten years
4. DForgetting to take the blood pressure tablet this morning

An older adult asks for something to help them sleep. Which drug is most likely to cause confusion and falls in this age group?

1. AMelatonin
2. BDiphenhydramine
3. CA warm milky drink
4. DAcetaminophen (paracetamol)

A medical-unit nurse is floated to intensive care and given a patient on a ventilator, which the nurse has never managed. What is the best response?

1. ALeave the intensive care unit and go back to the medical unit without telling anyone
2. BRefuse to work and go home, because the assignment is unsafe
3. CTell the charge nurse about the gap, accept tasks within competence and ask for support
4. DAccept the full assignment without comment to avoid conflict

Stebimas pacientas su galvos trauma ir kojos lūžiu. Kuris radinys yra prioritetas?

1. ANedidelis nubrozdinimas ant alkūnės
2. BPacientas prašo ko nors paskanauti
3. CGlazgo komos skalės balas krenta nuo 15 iki 12
4. D6/10 kojos skausmas, nepaisant paskutinės nuskausminamojo dozės