Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

Kuri iš šių yra viena iš penkių delegavimo „teisingų" sąlygų?

1. ATeisinga priežiūra ir vertinimas
2. BTeisingas laikas ir dažnumas
3. CTeisinga dozė ir stiprumas
4. DTeisingas vartojimo būdas ir injekcijos vieta

Which adult blood glucose result needs treatment straight away?

1. A52 mg/dL (2,9 mmol/L) with sweating and shakiness
2. B130 mg/dL (7,2 mmol/L) two hours after a large lunch
3. C110 mg/dL (6,1 mmol/L) after a snack
4. D98 mg/dL (5,4 mmol/L) before breakfast

Which resting heart rate in an adult is bradycardia?

1. A46/min
2. B88/min
3. C72/min
4. D64/min

During a blood transfusion, a patient develops chills, back pain and a fever. What is the nurse’s first action?

1. AStop the transfusion and keep the IV open with normal saline via new tubing
2. BSlow the transfusion and recheck in an hour
3. CFinish the unit quickly through a pressure bag so that the reaction does not last long
4. DGive an antipyretic and continue the transfusion

A patient has a reddened area on the sacrum that does not blanch when pressed. What is the priority action?

1. AMassage the area firmly to improve the blood flow to the skin
2. BRelieve pressure on the area by changing position regularly
3. CApply a heat pad to the area to increase circulation
4. DKeep the patient lying on the back to protect the area

A drowsy patient has an arterial blood gas with pH 7,30, PaCO₂ 58 mmHg (7,7 kPa) and HCO₃⁻ 25 mEq/L (mmol/L). Which problem is the priority?

1. AToo much bicarbonate from antacids
2. BLoss of bicarbonate from the bowel through severe diarrhea
3. CHyperventilation caused by anxiety
4. DPoor ventilation causing carbon dioxide to build up

Which nursing approach may raise intracranial pressure in a patient with a head injury?

1. AKeeping the room calm and quiet
2. BSpacing out care with rest periods in between activities
3. CKeeping the head in line with the body
4. DDoing suctioning, turning and bathing all at the same time

A patient at 34 weeks of pregnancy has painless, bright red vaginal bleeding. Which action should the nurse avoid?

1. AA vaginal examination
2. BMeasuring the blood pressure and pulse
3. CMonitoring the fetal heart rate
4. DWeighing the pads to estimate blood loss