Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

In a patient with sepsis, what does a raised blood lactate level suggest?

1. AThe liver is making too much bile
2. BThe tissues are not getting enough oxygen
3. CThe patient has eaten recently
4. DThe kidneys are working harder than usual

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

1. A4,0–5,0
2. B0,5–1,0
3. C6,0–7,0
4. D2,0–3,0

What is the purpose of the “time-out” just before a surgical procedure?

1. ATo count the swabs at the end of the operation
2. BTo let the family say goodbye to the patient
3. CTo give the surgeon a short rest before the operation starts
4. DTo confirm the correct patient, procedure and site

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

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

Which medication order should the nurse question?

1. APotassium chloride oral solution diluted in juice
2. BPotassium chloride diluted in an IV bag via a pump
3. COral potassium chloride with food
4. DPotassium chloride by IV push

A patient on hemodialysis has an arteriovenous fistula in the left arm. Which instruction should the nurse give the nursing assistant?

1. AHelp the patient carry shopping bags on the left arm
2. BDo not measure blood pressure on the left arm
3. CMeasure blood pressure on the left arm only, every 4 hours
4. DKeep the left arm wrapped tightly in a bandage at night

An adult choking on food is coughing forcefully and can speak a little. What should the nurse do?

1. ASweep the mouth blindly with a finger
2. BEncourage the patient to keep coughing and stay with them
3. CGive the patient water to wash the food down
4. DGive abdominal thrusts straight away until the food comes out

A patient on a cardiac monitor suddenly becomes unresponsive, and the monitor shows ventricular fibrillation. What is the priority once help has been called?

1. AGive an oral antiarrhythmic tablet and recheck the rhythm in five minutes
2. BDefibrillate as soon as the defibrillator is available, with CPR until then
3. CRecord a full 12-lead ECG to confirm the rhythm before doing anything else at all
4. DCheck the blood potassium level before any shock is considered