Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

When is the Apgar score usually assessed?

1. AAt 1 and 5 minutes after birth
2. BAt the first postnatal clinic visit
3. CBefore the baby is born
4. DOnly at 24 hours after birth

In most settings, which task is kept for the RN rather than assigned to an LPN/LVN?

1. AMeasuring vital signs
2. BGiving an IV push medication
3. CReinforcing teaching already given
4. DGiving scheduled oral medications

After caring for a patient with Clostridioides difficile diarrhea, how should the nurse clean their hands?

1. AWash with soap and water
2. BUse alcohol hand rub only
3. CNo hand hygiene is needed if gloves were worn
4. DWipe hands on a clean towel

A patient with type 1 diabetes has vomited since morning and cannot eat. Which action is most important?

1. ACheck the blood glucose and ketones and contact the provider
2. BStop all insulin until the patient is able to eat normally again
3. CWait until tomorrow to see if the vomiting settles
4. DEncourage a large meal to settle the stomach

A nurse teaches foot care to a patient with diabetes. Which statement shows a need for further teaching?

1. A“I will check the soles of my feet every day with a mirror.”
2. B“I will wear shoes that fit well, even at home.”
3. C“I will dry well between my toes after washing.”
4. D“I will soak my feet in hot water every evening.”

Which patient on an addiction unit should the nurse see first?

1. ALast drink two days ago; now shaking, sweating, heart rate 124/min and seeing insects
2. BLast drink this morning; asking when lunch will arrive
3. CLast drink one week ago; asking about support groups
4. DIn recovery for a year; came to the clinic today for a routine check and a repeat prescription

A patient taking an SSRI is also given tramadol. A few hours later the patient is agitated, sweating and has a fever, jerking muscles and brisk reflexes. What is the most likely cause?

1. AOpioid withdrawal
2. BNeuroleptic malignant syndrome
3. CSerotonin syndrome
4. DAn anxiety attack

A patient has a new spinal cord injury at C4. Which assessment is the priority?

1. ABowel sounds in all four abdominal quadrants
2. BBreathing effort and ability to cough
3. CAbility to feed themselves
4. DSkin over the sacrum and heels