Ustalanie priorytetów i delegowanie: karta pracy z odpowiedziami

Który problem pacjenta ma zasadniczo najwyższy priorytet?

1. ALęk
2. BOstry ból
3. CDeficyt wiedzy o lekach
4. DNiedrożność dróg oddechowych

What are Kussmaul respirations?

1. ADeep, rapid breathing seen in metabolic acidosis such as DKA
2. BNoisy, high-pitched breathing caused by a blocked upper airway
3. CSlow, shallow breathing after an opioid overdose
4. DShort pauses in breathing during normal sleep

What is the normal baseline fetal heart rate?

1. A40–60/min
2. B160–220/min
3. C110–160/min
4. D60–100/min

A patient with angina is taught to use sublingual nitroglycerin (GTN). Which statement shows a need for further teaching?

1. A“If the pain has not eased as my action plan says, I will call emergency services.”
2. B“I will carry the tablets with me when I go out.”
3. C“I will take five tablets one after the other before I call for help.”
4. D“I will sit or lie down when I take a tablet.”

On day 3 after hip surgery, a patient suddenly becomes short of breath with sharp chest pain and an SpO₂ of 88%. What should the nurse do first?

1. AGive the next dose of oral analgesia and reassess the patient in an hour
2. BMassage the patient’s calves to ease any muscle cramp
3. CRaise the head of the bed, give oxygen and call for urgent help
4. DEncourage the patient to walk to improve the circulation

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

A trauma patient has an open leg fracture, absent breath sounds on one side, a trachea shifted to the other side and a falling blood pressure. Which problem is the priority?

1. AThe open fracture of the leg
2. BThe suspected tension pneumothorax
3. CThe risk of wound infection
4. DThe pain from the fracture

A patient with septic shock remains hypotensive, with a mean arterial pressure of 58 mmHg, after adequate IV fluids. What should the nurse anticipate?

1. AA vasopressor, such as norepinephrine, to raise the pressure
2. BA loop diuretic to remove the extra fluid that has been given
3. CAn oral fluid challenge with a sports drink
4. DA beta-blocker to slow the heart rate