Ustalanie priorytetów i delegowanie: karta pracy z odpowiedziami

What is the CIWA scale used to assess?

1. AThe severity of alcohol withdrawal
2. BThe severity of a newborn’s jaundice
3. CThe risk of a pressure injury
4. DThe depth of a burn wound

Which three things does START triage check in a non-walking adult?

1. ARespirations, perfusion and mental status
2. BPain score, mobility and age
3. CPulse, blood pressure and body temperature
4. DAirway, blood glucose and pupils

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

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

Which patient on an addiction unit should the nurse see first?

1. ALast drink one week ago; asking about support groups
2. BLast drink this morning; asking when lunch will arrive
3. CIn recovery for a year; came to the clinic today for a routine check and a repeat prescription
4. DLast drink two days ago; now shaking, sweating, heart rate 124/min and seeing insects

Monitor kardiologiczny pokazuje u pacjenta linię płaską (asystolię), ale pacjent siedzi i rozmawia. Co robi pielęgniarka w pierwszej kolejności?

1. ANatychmiast rozpoczyna uciskanie klatki piersiowej
2. BWzywa zespół resuscytacyjny
3. CSprawdza pacjenta i przewody elektrod
4. DPrzygotowuje defibrylator do wykonania wstrząsu

Which finding is an early sign of compartment syndrome in a patient with a lower leg fracture?

1. AA strong pedal pulse with warm, pink toes and pain that settles with analgesia
2. BItching under the cast during the first week after it was applied
3. CPain out of proportion to the injury that worsens when the toes are stretched
4. DMild bruising around the fracture site on the second day

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

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

A patient admitted with a stroke this morning asks for a glass of water. What should the nurse do first?

1. AGive thickened fluids without checking the swallow
2. BGive the water through a straw so it goes down slowly
3. CCheck that a swallow screen has been done before giving anything by mouth
4. DAsk the family to help the patient drink while sitting upright in a chair at the bedside