Werkblad Prioriteren en delegeren met antwoorden

Which body temperature is a fever in an adult?

1. A36,8 °C
2. B37,1 °C
3. C38,5 °C
4. D36,4 °C

Which finding in an infant is a sign of breathing difficulty?

1. AWet diapers every few hours
2. BA strong cry
3. CNasal flaring
4. DPink, warm hands and feet

Welke behoefte wordt in het ABC-kader voor het stellen van verpleegkundige prioriteiten als eerste aangepakt?

1. APijn
2. BBreathing (ademhaling)
3. CCirculation (circulatie)
4. DAirway (luchtweg)

On a pediatric unit, which child does the nurse assess first?

1. AA child in a new arm cast with pink, warm fingers and pain of 5/10
2. BA child with asthma who is now quiet with very little air movement
3. CA child with croup who has a barking cough but no stridor at rest
4. DA child with a temperature of 38,2 °C after vaccination

A patient with angina is taught to use sublingual nitroglycerin (GTN). Which statement shows a need for further teaching?

1. A“I will carry the tablets with me when I go out.”
2. B“I will sit or lie down when I take a tablet.”
3. C“I will take five tablets one after the other before I call for help.”
4. D“If the pain has not eased as my action plan says, I will call emergency services.”

Een verpleegkundige delegeert routinematige vitale functies aan een zorgassistent voor een patiënt van wie de bloeddruk het laatste uur is gedaald. Aan welk juist punt van delegeren is niet voldaan?

1. AJuiste persoon
2. BJuiste aanwijzingen en communicatie
3. CJuiste taak, omdat vitale functies nooit gedelegeerd kunnen worden
4. DJuiste omstandigheid

A patient with a severe asthma attack had a PaCO₂ of 32 mmHg (4,3 kPa) on arrival. An hour later it is 46 mmHg (6,1 kPa), and the patient seems tired. What does this suggest?

1. AA laboratory error that should be ignored
2. BThe asthma is improving, because the PaCO₂ is now near normal
3. CRespiratory muscle fatigue with possible impending respiratory failure
4. DThe patient is hyperventilating even more than before and needs calming

A patient has a wrist restraint. The nurse finds the fingers on that hand pale, cool and tingling. What should the nurse do first?

1. ARaise the arm on a pillow and check again in two hours
2. BTighten the restraint so the patient moves less
3. CDocument the finding and continue with the medication round
4. DLoosen the restraint and assess the circulation