Ustalanie priorytetów i delegowanie: karta pracy z odpowiedziami

What is the CIWA scale used to assess?

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

Which serum lithium level suggests toxicity?

1. A0,8 mEq/L
2. B1,0 mEq/L
3. C2,2 mEq/L
4. D0,7 mEq/L

W trzystopniowym systemie triażu pacjent ze skręconą kostką, prawidłowymi parametrami życiowymi i łagodnym bólem jest zwykle zaklasyfikowany jako:

1. ANiepilny
2. BOczekujący (expectant)
3. CPilny
4. DNagły (emergent)

A nasogastric tube has just been placed for feeding. What must happen before the first feed is given?

1. APlacement is confirmed by an approved method
2. BThe tube is flushed with a large volume of water
3. CThe patient is asked if the tube feels comfortable
4. DThe feed is started slowly to see if the patient coughs

During a blood transfusion, a patient develops chills, back pain and a fever. What is the nurse’s first action?

1. AStop the transfusion and keep the IV open with normal saline via new tubing
2. BGive an antipyretic and continue the transfusion
3. CSlow the transfusion and recheck in an hour
4. DFinish the unit quickly through a pressure bag so that the reaction does not last long

A patient with a spinal cord injury at T4 suddenly has a severe headache, flushing above the injury and a blood pressure of 200/110 mmHg. What does the nurse do first?

1. AApply extra blankets to keep the patient warm and calm
2. BLay the patient flat with the legs raised
3. CGive a warm drink and recheck the blood pressure in an hour
4. DSit the patient upright with the legs lowered

A patient has a new spinal cord injury at C4. Which assessment is the priority?

1. ASkin over the sacrum and heels
2. BBowel sounds in all four abdominal quadrants
3. CBreathing effort and ability to cough
4. DAbility to feed themselves

On an addiction unit, which patient should the nurse assess first?

1. AYawning, with a runny nose and dilated pupils
2. BAnxious, with goose bumps, stomach cramps and loose stools
3. CDrowsy with pinpoint pupils and a respiratory rate of 7/min
4. DAsking for an extra blanket and a hot drink