Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

A patient has a Glasgow Coma Scale score of 8. What is the main concern?

1. AThe patient may not be able to protect the airway
2. BThe patient is fully alert and oriented
3. CThe patient can safely eat and drink without help
4. DThe patient only has a mild headache

Using the RACE fire response, what does the nurse do first when finding a fire in a patient’s room?

1. ARescue patients in immediate danger
2. BClose doors to contain the fire and smoke
3. CPull the fire alarm
4. DUse an extinguisher on the fire

What is the usual adult reference range for serum potassium?

1. AAbout 135–145 mEq/L
2. BAbout 3,5–5,0 mEq/L
3. CAbout 1,5–2,5 mEq/L
4. DAbout 6,0–8,0 mEq/L

A patient with schizophrenia says voices are telling him to hurt his roommate. What is the priority?

1. AIgnore the comment, because voices are part of his illness
2. BKeep everyone safe and tell the team, as the risk of harm is high
3. CTell him the voices are not real and leave him alone
4. DAsk the roommate to stay in the room with him and help calm him down

Atliekant START triažą, nevaikštantis suaugusysis kvėpuoja 22 kartus per minutę, turi stipininės arterijos pulsą ir vykdo paprastus nurodymus, bet turi akivaizdų kojos lūžį. Kokia kategorija jam suteikiama?

1. AŽalia (lengva)
2. BGeltona (atidėtina)
3. CJuoda (tikėtina mirtis)
4. DRaudona (neatidėliotina)

A patient has a new plaster cast that is still drying. How should the nurse handle it?

1. AWith the fingertips, pressing firmly to test it
2. BBy covering it tightly with a plastic sheet
3. CBy resting it directly on a hard surface
4. DWith the palms of the hands, not the fingertips

Two patients on the unit have the same surname. What should the nurse do before giving a medication?

1. AAsk the patient, “Are you Mr Smith?” and give the drug once he says yes
2. BUse the room number as the main identifier
3. CCheck two identifiers against the wristband and the medication record
4. DAsk a nursing assistant which patient is which

A patient with a severe asthma attack had a PaCO₂ of 32 mmHg (4,3 kPa) on arrival. An hour later it is 46 mmHg (6,1 kPa), and the patient seems tired. What does this suggest?

1. AThe patient is hyperventilating even more than before and needs calming
2. BRespiratory muscle fatigue with possible impending respiratory failure
3. CThe asthma is improving, because the PaCO₂ is now near normal
4. DA laboratory error that should be ignored