Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

In the Emergency Severity Index (ESI), which patient fits level 2?

1. AA patient who needs an immediate life-saving intervention to survive
2. BA high-risk situation, new confusion, or severe pain or distress
3. CA stable patient who needs one resource
4. DA stable patient who needs no resources

Which drug reverses the anticoagulant effect of heparin?

1. AVitamin K
2. BNaloxone
3. CProtamine sulfate
4. DAtropine

In a three-level triage system, what does “urgent” mean?

1. AMinor, and can safely wait for several hours
2. BSerious but stable for now, and needs care soon
3. CAlready deceased on arrival
4. DLife-threatening and needs care immediately

A conscious patient with hypoglycemia drank juice 15 minutes ago. The glucose is now 62 mg/dL (3,4 mmol/L). What should the nurse do next?

1. AGive another serving of fast-acting carbohydrate and recheck in 15 minutes
2. BRecord the result and recheck the glucose at the usual time before the evening meal
3. CWait another hour, because juice can take a long time to work
4. DGive the next scheduled dose of rapid-acting insulin with the meal

One day after surgery, a patient walked safely with the RN this morning. The RN now asks a nursing assistant to walk her again. Which instruction is most important?

1. A“Try to finish the walk before the lunch trays arrive.”
2. B“Make sure she wears her own slippers if she has them.”
3. C“Stop and call me at once if she feels dizzy or short of breath.”
4. D“Walk her to the end of the corridor and back twice before lunch.”

On day 3 after hip surgery, a patient suddenly becomes short of breath with sharp chest pain and an SpO₂ of 88%. What should the nurse do first?

1. AGive the next dose of oral analgesia and reassess the patient in an hour
2. BEncourage the patient to walk to improve the circulation
3. CRaise the head of the bed, give oxygen and call for urgent help
4. DMassage the patient’s calves to ease any muscle cramp

Which finding most suggests a tension pneumothorax rather than a simple pneumothorax?

1. ATrachea shifted away from the affected side, with low blood pressure
2. BA small air leak seen on a routine chest X-ray
3. CMild breathlessness with reduced breath sounds on one side of the chest only
4. DSharp chest pain that is worse on deep breathing

After a head injury, a patient passes large amounts of very dilute urine, is thirsty and has a rising serum sodium. Which condition is most likely?

1. AAcute kidney injury with oliguria
2. BDiabetic ketoacidosis
3. CDiabetes insipidus
4. DSIADH