Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

Who is responsible for developing the nursing plan of care?

1. AThe nursing assistant
2. BThe registered nurse
3. CThe ward clerk
4. DThe LPN/LVN alone

Trijų lygių triažo sistemoje pacientas su išnirusia kulkšnimi, normaliais gyvybiniais rodikliais ir lengvu skausmu paprastai priskiriamas:

1. ANeskubiems
2. BTikėtinos mirties
3. CSkubiems
4. DSkubiausiems (neatidėliotiniems)

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. CShallow breaths with an SpO₂ of 85% on room air
4. DStridor caused by a swollen throat

A patient with a head injury is being monitored. Which set of findings suggests rising intracranial pressure?

1. ARising systolic pressure, slow pulse and irregular breathing
2. BFalling blood pressure, a fast pulse and warm, flushed dry skin
3. CNormal blood pressure, normal pulse and clear speech
4. DLow temperature, fast breathing and a strong appetite

On day 3 after hip surgery, a patient suddenly becomes short of breath with sharp chest pain and an SpO₂ of 88%. What should the nurse do first?

1. AEncourage the patient to walk to improve the circulation
2. BMassage the patient’s calves to ease any muscle cramp
3. CGive the next dose of oral analgesia and reassess the patient in an hour
4. DRaise the head of the bed, give oxygen and call for urgent help

A nurse teaches a patient who has started warfarin. Which statement shows a need for further teaching?

1. A“I will use a soft toothbrush.”
2. B“I will tell my dentist and pharmacist that I take warfarin.”
3. C“I will keep my INR blood test appointments.”
4. D“If I miss a dose, I will take two the next day.”

A patient arrives one hour after the start of stroke symptoms. Which step must happen before a thrombolytic drug can be given?

1. AAn echocardiogram to look for clots
2. BA full lipid profile to check cholesterol
3. CA swallow test with a cup of water
4. DA brain scan to rule out bleeding

Pacientas, sergantis širdies nepakankamumu, dūsta, abiejuose plaučiuose girdimi karkalai. Kuri veiksmų eilė teisinga?

1. APasodinti tiesiai, duoti deguonies pagal paskyrimą, tada kviesti gydytoją
2. BPirmiausia duoti paskirtus geriamuosius vaistus, tada pasodinti pacientą
3. CPirmiausia pasverti pacientą, tada po keturių valandų iš naujo įvertinti kvėpavimą
4. DPaguldyti pacientą ilsėtis, tada pradėti palaikomuosius skysčius į veną