Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

What does the Morse Fall Scale measure?

1. AA patient’s risk of falling
2. BA patient’s nutrition status
3. CA patient’s skin integrity
4. DA patient’s pain level

Which drug is used to reverse the effect of warfarin?

1. AFlumazenil
2. BVitamin K
3. CProtamine sulfate
4. DNaloxone

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

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

Which patient with diabetes should the nurse see first?

1. AHbA1c result of 8,2%, asking about diet
2. BGlucose 210 mg/dL (11,7 mmol/L) after a large lunch, feels well
3. CNeeds foot care teaching before discharge tomorrow
4. DGlucose 48 mg/dL (2,7 mmol/L), sweating and confused

A patient has a nasogastric tube on suction. Which task can the nurse delegate to a nursing assistant?

1. AIrrigating the tube when it blocks
2. BGiving mouth care
3. CAssessing the drainage for blood
4. DChecking the tube’s position

A patient is raising his voice, pacing and clenching his fists. What should the nurse do first?

1. ATurn away and ignore the behavior
2. BStand very close to him and tell him firmly and loudly to sit down and be quiet
3. CSpeak calmly, keep a safe distance and invite him to talk about what is wrong
4. DApply physical restraints at once

Po pamainos perdavimo, kurį pacientą slaugytojas turėtų įvertinti pirmiausia?

1. A2 diena po tulžies pūslės operacijos: skausmas 6/10, kita nuskausminamojo dozė po 30 minučių
2. B2 tipo diabetas: gliukozė 210 mg/dL (11,7 mmol/L) prieš pietus, simptomų nėra
3. CLOPL su 2 L/min deguonimi: SpO₂ 90 %, kvėpavimo dažnis 22/min, įprastame pradiniame lygyje
4. DPraėjus 1 valandai po šlaunies arterijos širdies kateterizacijos: naujas nugaros skausmas, pulsas 118/min, KS 92/58 mmHg

During birth, the baby’s head delivers but the shoulders do not follow. What should the nurse do first?

1. APush firmly on the top of the uterus (fundal pressure)
2. BAsk the mother to stop pushing and wait an hour
3. CPull hard on the baby’s head and neck to free the trapped shoulders quickly
4. DHelp with the McRoberts position and give suprapubic pressure as directed