Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

Which finding meets the usual definition of orthostatic hypotension?

1. AHeart rate falls by 5/min after lying down
2. BSystolic pressure rises by 20 mmHg or more within 3 minutes of standing up
3. CSystolic pressure falls by 20 mmHg or more within 3 minutes of standing
4. DBlood pressure is the same lying and standing

A nurse is worried about a patient’s worsening condition, and the provider does not respond to the concern. Following the chain of command, whom does the nurse usually contact next?

1. AThe hospital’s chief executive
2. BThe patient’s next of kin
3. CThe pharmacy technician on duty that day
4. DThe charge nurse or nursing supervisor

Which resting heart rate in an adult is bradycardia?

1. A72/min
2. B46/min
3. C64/min
4. D88/min

One hour after a vaginal birth, the nurse finds a soft, boggy uterus and heavy bleeding. What is the first action?

1. AOffer a meal and fluids
2. BApply an ice pack to the perineum
3. CMassage the fundus
4. DEncourage the patient to rest quietly

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 out slowly through pursed lips.”
3. C“I will breathe in through my mouth and out quickly through my nose.”
4. D“I will breathe in slowly through my nose.”

A patient with a valid do-not-resuscitate order (DNR; called DNACPR in the UK) stops breathing and has no pulse. What should the nurse do?

1. AStart CPR and stop when the family arrives
2. BCall the cardiac arrest team and let them decide
3. CStart chest compressions but not rescue breaths
4. DFollow the DNR order and do not start CPR

A patient admitted with a stroke this morning asks for a glass of water. What should the nurse do first?

1. ACheck that a swallow screen has been done before giving anything by mouth
2. BGive the water through a straw so it goes down slowly
3. CAsk the family to help the patient drink while sitting upright in a chair at the bedside
4. DGive thickened fluids without checking the swallow

Which finding after a laparoscopic cholecystectomy is expected and needs only reassurance and comfort measures?

1. AYellow skin with dark urine on the second day
2. BA heart rate of 125/min with a falling blood pressure
3. CRight shoulder pain from the gas used during surgery
4. DIncreasing abdominal pain with a temperature of 39 °C