Ustalanie priorytetów i delegowanie: karta pracy z odpowiedziami

What does the START in START triage stand for?

1. ASimple Triage And Rapid Treatment
2. BStaged Triage And Resuscitation Team
3. CStandard Treatment And Referral Tool
4. DSystematic Transfer And Rapid Transport

What does NPO mean on a patient’s care plan?

1. ANo pain observed
2. BNormal patient observations
3. CNot for physical therapy
4. DNothing by mouth

Asystent pielęgniarski zgłasza cztery przypadki. Który powinna sprawdzić pielęgniarka w pierwszej kolejności?

1. APacjenta, który nagle nie może poruszać prawą ręką
2. BPacjenta, który chce zadzwonić do krewnego
3. CPacjenta, który prosi o dodatkowy koc
4. DPacjenta, który nie zjadł całego śniadania

A patient receiving IV magnesium sulfate for pre-eclampsia has absent knee reflexes and a respiratory rate of 10/min. What does the nurse do first?

1. AIncrease the infusion to prevent a seizure
2. BGive oral fluids to help clear the drug faster
3. CTurn the patient onto her back and recheck later
4. DStop the magnesium infusion and call for help

A pregnant nurse is on the unit. Which patient should the charge nurse avoid assigning to her?

1. AA patient after a hip replacement
2. BA patient with a fractured wrist
3. CA patient with a sealed radioactive implant for cervical cancer
4. DA patient with type 2 diabetes who needs insulin teaching before discharge

A patient with a head injury is being monitored. Which set of findings suggests rising intracranial pressure?

1. AFalling blood pressure, a fast pulse and warm, flushed dry skin
2. BNormal blood pressure, normal pulse and clear speech
3. CLow temperature, fast breathing and a strong appetite
4. DRising systolic pressure, slow pulse and irregular breathing

Which finding most suggests a tension pneumothorax rather than a simple pneumothorax?

1. ATrachea shifted away from the affected side, with low blood pressure
2. BMild breathlessness with reduced breath sounds on one side of the chest only
3. CA small air leak seen on a routine chest X-ray
4. DSharp chest pain that is worse on deep breathing

A patient with Guillain-Barré syndrome has weakness that is spreading up from the legs. Which assessment has the highest priority?

1. AThe patient’s mood and coping
2. BSkin condition over the heels
3. CMuscle strength in the feet and ankles at the start of each morning
4. DBreathing strength, such as vital capacity and the ability to cough