Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

In the ABC framework, which finding is mainly a breathing problem?

1. AHeart rate 150/min with a low blood pressure and cold skin
2. BA blood glucose of 60 mg/dL (3,3 mmol/L)
3. CStridor caused by a swollen throat
4. DShallow breaths with an SpO₂ of 85% on room air

A patient’s urine output is 15 mL/h for three hours. How should the nurse classify this in an adult?

1. AHigh, suggesting fluid overload
2. BExpected after drinking fluids
3. CNormal for an adult at rest
4. DLow and needing to be reported

A medication error has just reached a patient. What is the nurse’s first action?

1. ATell the nurse manager at the end of the shift
2. BAssess the patient for any effects of the error
3. CComplete an incident report before doing anything else
4. DCorrect the entry on the medication record

Kurią užduotį slaugytojas turėtų deleguoti slaugytojo padėjėjui pacientui, kuriam taikomos kritimų prevencijos priemonės?

1. APaciento kritimo rizikos balo įvertinimą ir užrašymą kiekvieną rytą
2. BSprendimą, ar vis dar reikalingas lovos signalizatorius
3. CPagalbą pacientui nueiti į tualetą kas 2 valandas, kaip suplanuota
4. DŠeimos mokymą, kaip išvengti kritimų namuose

During an IV vancomycin infusion, a patient develops flushing and itching of the face and neck. What should the nurse do first?

1. AIgnore it, because flushing is always harmless and passes
2. BSpeed up the infusion to finish it quickly
3. CApply a warm compress to the face and neck
4. DStop or slow the infusion and inform the provider

A young adult has just started an SSRI antidepressant for major depression. What should the nurse monitor most closely in the first weeks?

1. AWeight loss from too much appetite
2. BHair growth and skin color
3. CThoughts of suicide or self-harm
4. DRising blood glucose levels

A patient in acute mania paces constantly, has lost weight and will not sit down to eat. Which intervention is most helpful?

1. AInsist that the patient sits at the table until the meal is finished
2. BOffer high-calorie finger foods and drinks the patient can take while moving
3. CLeave meals in the room and let the patient eat whenever and whatever they choose
4. DWait until the mania settles before worrying about nutrition

A patient on peritoneal dialysis has cloudy fluid draining out and abdominal pain. What does this most likely mean?

1. AConstipation that will settle with a laxative later today or tomorrow
2. BA normal finding at the end of each exchange
3. CPeritonitis, which needs prompt reporting and a fluid sample
4. DToo much fluid left in the abdomen after the drain