Ustalanie priorytetów i delegowanie: karta pracy z odpowiedziami

Which finding is expected in a patient with long-standing COPD?

1. AAn SpO₂ of 78%
2. BA barrel-shaped chest
3. CSudden sharp chest pain
4. DNew confusion

Using the RACE fire response, what does the nurse do first when finding a fire in a patient’s room?

1. APull the fire alarm
2. BClose doors to contain the fire and smoke
3. CRescue patients in immediate danger
4. DUse an extinguisher on the fire

A patient’s platelet count is 18,000/mm³ (18 × 10⁹/L). Which risk is the nursing priority?

1. ABleeding
2. BInfection
3. CFluid overload
4. DBlood clots

A patient on a continuous IV heparin infusion has new black, tarry stools and an aPTT well above the target range. What should the nurse do first?

1. AStop the heparin infusion and inform the provider
2. BGive a dose of vitamin K by mouth
3. CCheck the pump rate and leave the infusion running
4. DOffer an iron-rich meal to replace the lost blood

Pielęgniarka oddziałowa musi zwolnić łóżko. Którego pacjenta najodpowiedniej wypisać lub przenieść na niższy poziom opieki?

1. APrzyjęty dwie godziny temu z bólem w klatce piersiowej; wynik troponiny jeszcze oczekiwany
2. B1. doba po operacji jelita z nową temperaturą 38,5 °C
3. CZapalenie płuc, z zapotrzebowaniem na tlen, które w nocy wzrosło z 2 do 4 L/min
4. D3. doba po niepowikłanym wycięciu wyrostka robaczkowego, je, przyjmuje doustne leki przeciwbólowe

Which postoperative patient should the nurse see first?

1. ADressing soaked with bright red blood and a heart rate rising to 118/min
2. BWants help with washing her hair before her visitors arrive this afternoon
3. CAsking when the urinary catheter will be removed
4. DPain of 4/10 one hour after an oral analgesic

Six hours after surgery, a patient has not passed urine, feels the urge to go and has a firm swelling above the pubic bone. What is the most likely problem?

1. AAcute kidney injury with no urine made
2. BDehydration from fasting before surgery
3. CA normal effect of the anesthetic
4. DUrinary retention

An infant with pyloric stenosis has repeated projectile vomiting. Which acid-base imbalance is most likely?

1. ARespiratory acidosis
2. BRespiratory alkalosis
3. CMetabolic alkalosis
4. DMetabolic acidosis