Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

Kuris radinys yra kvėpavimo takų problema?

1. ALiežuvio ir lūpų tinimas su užkimusiu balsu
2. BSilpnas, siūliškas stipininės arterijos pulsas
3. CPilvo skausmas, vertinamas 8/10
4. DĮkvepiant girdimi smulkūs karkalai abiejų plaučių pagrinduose

Which drug reverses the anticoagulant effect of heparin?

1. AProtamine sulfate
2. BVitamin K
3. CAtropine
4. DNaloxone

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

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

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

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

Which action helps prevent a catheter-associated urinary tract infection?

1. ADisconnecting the bag every shift to empty it
2. BKeeping the drainage bag below the level of the bladder
3. CRaising the drainage bag above the bladder when walking
4. DLeaving the catheter in place longer than needed

A nursing assistant tells the RN that a patient’s IV pump is alarming. What is the best response?

1. A“Increase the rate a little so the alarm clears.”
2. B“Turn the pump off and on again until it stops.”
3. C“I will come and check the pump and the IV site now.”
4. D“Silence the alarm and I will check it at the end of the shift.”

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

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

A team has an RN, an LPN/LVN and a nursing assistant. Which task is the best one to assign to the LPN/LVN?

1. AAssessing a patient who returned from surgery 30 minutes ago
2. BWriting the discharge teaching plan for a patient with new diabetes
3. CGiving a scheduled subcutaneous anticoagulant injection to a stable patient
4. DMeasuring the vital signs and weights of every patient on the unit before breakfast