Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

Which finding is expected in a patient with long-standing COPD?

1. ASudden sharp chest pain
2. BA barrel-shaped chest
3. CAn SpO₂ of 78%
4. DNew confusion

A patient’s platelet count is 18,000/mm³ (18 × 10⁹/L). Which risk is the nursing priority?

1. AInfection
2. BBleeding
3. CBlood clots
4. DFluid overload

Which statement about pulse oximetry is correct?

1. AIt measures the carbon dioxide in the blood
2. BCold fingers or nail polish can give an inaccurate reading
3. CIt shows the patient’s blood glucose
4. DThe reading is always correct, whatever finger or hand is used

A nurse teaches a patient with COPD pursed-lip breathing. Which statement shows a need for further teaching?

1. A“I will make my breath out about twice as long as my breath in.”
2. B“I will breathe in slowly through my nose.”
3. C“I will breathe out slowly through pursed lips.”
4. D“I will breathe in through my mouth and out quickly through my nose.”

A patient with asthma uses a peak flow meter. A reading below 50% of personal best is in the red zone. Which statement shows correct understanding?

1. A“I will wait until tomorrow morning to see if the reading gets better on its own.”
2. B“I will go for a short run to open up my lungs.”
3. C“I will use my reliever inhaler and get emergency help straight away.”
4. D“I will stop all my inhalers until the reading is back up.”

During a blood transfusion, a patient develops chills, back pain and a fever. What is the nurse’s first action?

1. ASlow the transfusion and recheck in an hour
2. BFinish the unit quickly through a pressure bag so that the reaction does not last long
3. CGive an antipyretic and continue the transfusion
4. DStop the transfusion and keep the IV open with normal saline via new tubing

After a head injury, a patient has clear fluid dripping from the nose. Which action should the nurse avoid?

1. APlacing a loose gauze under the nose
2. BInforming the provider about the drainage
3. CChecking the fluid for glucose or a halo sign on gauze
4. DInserting a tube or suction catheter through the nose

A patient with severe sepsis starts oozing blood from IV sites and the gums, and bruises appear on the skin. What should the nurse suspect?

1. ADisseminated intravascular coagulation (DIC)
2. BNormal bruising from blood tests
3. CVitamin C deficiency
4. DAn allergic reaction to the adhesive tape