Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

Which finding should a nursing assistant report to the nurse at once?

1. AA patient who would like tea instead of coffee
2. BA patient whose weight is unchanged from yesterday
3. CA patient who wants to shower in the evening
4. DA pulse of 42/min in a patient whose usual pulse is 76/min

In Maslow’s hierarchy of needs, which level sits at the top?

1. ASafety and security
2. BSelf-actualization
3. CEsteem
4. DLove and belonging

Which fasting blood glucose value is normal for an adult without diabetes?

1. A210 mg/dL (11,7 mmol/L)
2. B85 mg/dL (4,7 mmol/L)
3. C145 mg/dL (8,0 mmol/L)
4. D55 mg/dL (3,1 mmol/L)

A patient on hemodialysis has an arteriovenous fistula in the left arm. Which instruction should the nurse give the nursing assistant?

1. AHelp the patient carry shopping bags on the left arm
2. BMeasure blood pressure on the left arm only, every 4 hours
3. CKeep the left arm wrapped tightly in a bandage at night
4. DDo not measure blood pressure on the left arm

Which patient is at the highest risk of falling?

1. AA 30-year-old after an appendectomy who walks with steady steps
2. BA 60-year-old admitted for chest pain that has since been ruled out by tests
3. CA 45-year-old with asthma who is alert and independent
4. DAn 84-year-old taking a diuretic who has fallen before and gets up at night

During labor, the nurse sees the umbilical cord in the vagina after the membranes rupture. What is the first action?

1. ARelieve pressure on the cord by lifting the presenting part with a gloved hand
2. BPush the cord back into the uterus
3. CAsk the patient to walk around the room to bring the baby lower and speed up labor
4. DWait for the next contraction before acting

A day after a femur fracture, a young patient becomes confused and breathless, with small red spots on the chest. What should the nurse suspect?

1. AAn allergic reaction to the cast
2. BFat embolism syndrome
3. CAlcohol withdrawal
4. DNormal pain after a fracture

During JumpSTART triage, a child is not breathing after the airway is opened but has a palpable pulse. What is the next step?

1. AGive five rescue breaths; if breathing starts, tag the child red
2. BStart full CPR on the child and stay with them until more help arrives
3. CTag the child black at once and move on to the next victim
4. DTag the child green and return to them after the others