Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

What is the normal baseline fetal heart rate?

1. A40–60/min
2. B60–100/min
3. C110–160/min
4. D160–220/min

In which situation can a pulse oximeter give a falsely normal reading?

1. AA patient breathing room air normally
2. BA warm, well-perfused finger
3. CA healthy adult at rest
4. DCarbon monoxide poisoning

Ką Skubios pagalbos sunkumo indekse (ESI) reiškia 1 lygis?

1. ATai mažiausiai skubus pacientas
2. BReikia dviejų ar daugiau išteklių
3. CReikia neatidėliotinos gyvybę gelbstinčios intervencijos
4. DPakankamai stabilus, kad būtų priimtas greitojo priėmimo zonoje

A patient has heart failure. Which instruction about daily weights is best to give the nursing assistant?

1. A“Weigh him after lunch, fully dressed, with his shoes on.”
2. B“Only weigh him if his ankles look more swollen than they did yesterday afternoon.”
3. C“Weigh him at any time today, on whichever scale is free.”
4. D“Weigh him each morning before breakfast, on the same scale, and tell me the result.”

A patient with asthma uses a peak flow meter. A reading below 50% of personal best is in the red zone. Which statement shows correct understanding?

1. A“I will go for a short run to open up my lungs.”
2. B“I will stop all my inhalers until the reading is back up.”
3. C“I will wait until tomorrow morning to see if the reading gets better on its own.”
4. D“I will use my reliever inhaler and get emergency help straight away.”

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. CGive an antipyretic and continue the transfusion
4. DFinish the unit quickly through a pressure bag so that the reaction does not last long

A patient has a new spinal cord injury at C4. Which assessment is the priority?

1. ABreathing effort and ability to cough
2. BAbility to feed themselves
3. CSkin over the sacrum and heels
4. DBowel sounds in all four abdominal quadrants

A patient with diabetic ketoacidosis is about to start an IV insulin infusion. The serum potassium is 3,0 mEq/L. What should the nurse do?

1. AGive the insulin as a fast bolus to bring the potassium up
2. BStart the insulin at once, because the glucose is the bigger problem
3. CIgnore the result, since potassium is always high in this condition and will correct itself
4. DReport the result before starting, because insulin will push potassium even lower