Pielęgniarstwo kliniczne: karta pracy z odpowiedziami

Jaki jest najniższy możliwy wynik w skali śpiączki Glasgow?

1. A5
2. B3
3. C1
4. D0

Jaki jest najważniejszy sposób zapobiegania odleżynom u pacjenta leżącego?

1. AOgraniczanie płynów
2. BUtrzymywanie pacjenta w jednej pozycji przez cały dzień
3. CMocne masowanie zaczerwienionych miejsc
4. DRegularna zmiana pozycji w celu odciążenia ucisku

Wymioty „fusowate” sugerują:

1. ANiedrożność w dolnym odcinku okrężnicy
2. BKrwawienie z górnego odcinka przewodu pokarmowego
3. CNiewydolność nerek
4. DZatrucie pokarmowe z wymiotami, ale bez żadnego krwawienia

A patient with Guillain–Barré syndrome has weakness spreading upwards from the legs. Which monitoring is most important?

1. AVisual acuity
2. BBlood glucose, measured once a day before breakfast
3. CWeekly weight
4. DBreathing function, such as forced vital capacity

After removing a peripheral IV cannula, what should the nurse check?

1. AThat the patient's blood glucose is normal before removal
2. BThat the cannula is intact, and apply pressure until bleeding stops
3. CThat the site is left uncovered and bleeding freely
4. DThat the cannula is put back in its sterile packet for the next patient

Which features suggest Cushing's syndrome?

1. AWeight loss, heat intolerance, tremor and protruding eyes
2. BCoarse facial features and very large hands and feet
3. CDark skin, low blood pressure, salt craving and a low blood sodium level
4. DWeight gain around the trunk, a rounded face and thin, easily bruised skin

A postoperative patient on IV fluids has a sodium of 128 mmol/L and is becoming confused. Which fluid could make this worse if given in large amounts?

1. A0,9% sodium chloride
2. B5% glucose (D5W)
3. CHuman albumin solution
4. DHartmann's solution (similar to lactated Ringer's)

During a blood transfusion, an older patient with heart failure becomes breathless with a rising blood pressure, raised JVP and crackles in the lungs. What is the most likely cause?

1. ATransfusion-related acute lung injury with hypotension
2. BA febrile non-haemolytic reaction
3. CTransfusion-associated circulatory overload
4. DAnaphylaxis