Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

What should the nurse try before using physical restraints on a confused patient?

1. ARestraining all four limbs to be fully safe
2. BUsing restraints at once and removing them later if they turn out not to be needed
3. CAsking the family to bring restraints from home
4. DLess restrictive measures, such as more frequent checks or a bed alarm

In delegation, what does the “right task” mean?

1. AThe task is the one the nurse likes least
2. BThe task can be finished in under ten minutes
3. CThe task is one that may be delegated for this patient
4. DThe task has been requested by the patient or the patient’s family

In SBAR communication, what does the letter R stand for?

1. AResponse
2. BRecommendation
3. CReassessment
4. DResult

A patient with type 1 diabetes has vomited since morning and cannot eat. Which action is most important?

1. ACheck the blood glucose and ketones and contact the provider
2. BStop all insulin until the patient is able to eat normally again
3. CWait until tomorrow to see if the vomiting settles
4. DEncourage a large meal to settle the stomach

Before accessing a central venous catheter, what should the nurse do to prevent infection?

1. ATouch the hub to check it is clean
2. BRinse the hub with tap water and dry it
3. CBlow on the hub to remove any dust before connecting the syringe or line
4. DScrub the hub with an antiseptic such as chlorhexidine and let it dry

A patient’s chest tube becomes disconnected from the drainage system. What should the nurse do first?

1. ARemove the tube and cover the site
2. BPlace the end of the tube in a bottle of sterile water
3. CWait for the provider to arrive before doing anything else
4. DClamp the tube for the rest of the shift

Kurio paciento radinys yra skubiausias?

1. APacientas, kurio trombocitų skaičiaus rezultatas dar laukiamas
2. BPacientas po kelio operacijos su nedidele mėlyne injekcijos vietoje
3. CPacientas, vartojantis varfariną, kurio INR 2,5 ir kuriam metas gauti įprastą vakarinę dozę
4. DPacientas, gaunantis heparino infuziją, naujai sumišęs ir turintis stiprų galvos skausmą

Kurį pacientą slaugytojas turėtų pirmiausia eskaluoti skubaus reagavimo komandai?

1. APacientą, kuriam žinoma hipertenzija, kurio kraujospūdis 152/94 mmHg ir kuris jaučiasi gerai
2. BPacientą po kelio operacijos su 6/10 skausmu ir normaliais gyvybiniais rodikliais
3. CPacientą, sergantį celiulitu, kurio temperatūra 38,1 °C, o kiti gyvybiniai rodikliai normalūs
4. DPacientą, sergantį šlapimo takų infekcija, kuris naujai susimaišė, kvėpavimo dažnis 26/min, o sistolinis kraujospūdis 94 mmHg