Ustalanie priorytetów i delegowanie: karta pracy z odpowiedziami

A patient’s urine output is 15 mL/h for three hours. How should the nurse classify this in an adult?

1. AExpected after drinking fluids
2. BHigh, suggesting fluid overload
3. CNormal for an adult at rest
4. DLow and needing to be reported

W delegowaniu, co oznaczają „właściwe wskazówki i komunikacja”?

1. APowiedzenie osobie wykonującej, by kierowała się własnym osądem
2. BJasne, szczegółowe instrukcje: co zrobić, kiedy i o czym zgłosić z powrotem
3. CZapisanie zadania wyłącznie w dokumentacji pacjenta
4. DPoproszenie osoby wykonującej, by zgłosiła niezwykłe ustalenia pod koniec dyżuru

Which phrase in a question usually signals a priority question?

1. A“Which bone is found in the forearm?”
2. B“Which statement describes this drug’s class?”
3. C“Which action should the nurse take first?”
4. D“Which term means inflammation of the liver?”

Który objaw jest nieoczekiwany i wymaga szybkiej reakcji?

1. APacjent dzień po laparoskopowej operacji pęcherzyka żółciowego ma ból prawego barku
2. BPacjent z wlewem heparyny ma nowy czarny, smolisty stolec
3. CPacjent z wieloletnią POChP ma beczkowatą klatkę piersiową
4. DPacjent ze znaną marskością ma żółtą skórę, która się nie zmieniła

Several patients on a gastroenterology unit need care. Which patient should the nurse see first?

1. ACrohn disease, waiting to be taken down for a scheduled CT scan
2. BTwo hours after a colonoscopy: rigid abdomen and severe new pain
3. CUlcerative colitis, asking about diet changes for home
4. DLong-standing back pain, asking for the usual analgesic

Which patient is most suitable for the nurse to assign to a nurse who has just finished orientation?

1. AA patient on a continuous heparin infusion with rising aPTT values
2. BA patient with a new tracheostomy who needs frequent suctioning
3. CA patient with sepsis whose blood pressure is falling
4. DA patient with stable cellulitis on scheduled IV antibiotics

A patient is bleeding internally after a fall. Which finding is usually an early sign of hypovolemic shock?

1. ARestlessness and a rising heart rate while the blood pressure is still normal
2. BA very low blood pressure with fixed, dilated pupils
3. CLoss of consciousness with gasping breaths
4. DA slow heart rate with warm, dry, flushed skin and a normal blood pressure throughout

A child who had a tonsillectomy this morning is swallowing again and again while asleep. What should the nurse suspect?

1. ANormal swallowing during sleep
2. BA sore throat from the breathing tube
3. CBleeding from the operation site
4. DHunger after fasting for surgery