Užduočių lapas tema Prioritetų nustatymas ir delegavimas su atsakymais

What is the usual adult reference range for serum potassium?

1. AAbout 135–145 mEq/L
2. BAbout 3,5–5,0 mEq/L
3. CAbout 6,0–8,0 mEq/L
4. DAbout 1,5–2,5 mEq/L

When is the Apgar score usually assessed?

1. AAt the first postnatal clinic visit
2. BAt 1 and 5 minutes after birth
3. CBefore the baby is born
4. DOnly at 24 hours after birth

Which statement belongs in the Background part of an SBAR report?

1. A“I think he may be developing sepsis.”
2. B“I am calling about Mr Khan because his blood pressure has dropped.”
3. C“I would like you to see him within the next 15 minutes.”
4. D“He was admitted three days ago with pneumonia and also has COPD.”

During a blood transfusion, a patient develops chills, back pain and a fever. What is the nurse’s first action?

1. AFinish the unit quickly through a pressure bag so that the reaction does not last long
2. BStop the transfusion and keep the IV open with normal saline via new tubing
3. CGive an antipyretic and continue the transfusion
4. DSlow the transfusion and recheck in an hour

On the first day after abdominal surgery, a patient has a temperature of 37,9 °C and reduced breath sounds at the lung bases. Which nursing action is most helpful?

1. AEncourage deep breathing, coughing and use of the incentive spirometer
2. BKeep the patient lying flat in bed to rest the incision fully
3. CGive a cough suppressant so that the incision is not strained
4. DRestrict oral fluids so that the lungs do not fill up with extra fluid

A patient’s urinary catheter has drained no urine for two hours, and the lower abdomen is swollen. What should the nurse do first?

1. ARemove the catheter and wait for the patient to void
2. BEncourage the patient to drink more water
3. CCheck the tubing for kinks or obstruction
4. DGive a prescribed diuretic straight away

A competent adult patient refuses a blood transfusion for religious reasons. What should the nurse do?

1. ATell the patient that refusing treatment is not allowed in hospital
2. BAsk the family to persuade the patient until they agree
3. CGive the transfusion while the patient is asleep, because saving their life comes first
4. DRespect the refusal, check the patient understands the risks and inform the provider

A charge nurse notices that a nurse smells of alcohol and is slurring words at the start of the shift. What is the priority?

1. AWait until the end of the shift and then discuss the concern with the nurse privately
2. BLet the nurse work, but only with stable patients
3. CAsk the nurse to drink coffee and then start work
4. DRemove the nurse from patient care and report it according to policy