Ustalanie priorytetów i delegowanie: karta pracy z odpowiedziami

Which finding in an infant is a sign of breathing difficulty?

1. APink, warm hands and feet
2. BA strong cry
3. CNasal flaring
4. DWet diapers every few hours

W schemacie ABC, który problem dotyczy krążenia?

1. ANiekontrolowane krwawienie
2. BStridor
3. CLęk
4. DCzęstość oddechów 32/min

Which body temperature is a fever in an adult?

1. A36,8 °C
2. B38,5 °C
3. C37,1 °C
4. D36,4 °C

Which action by a nursing assistant needs the nurse to step in?

1. ATaking an oral temperature just after the patient drank cold water
2. BLowering the bed to its lowest position and locking the wheels after care
3. CPutting the call light within the patient’s reach
4. DCleaning hands before entering the room

Before accessing a central venous catheter, what should the nurse do to prevent infection?

1. ATouch the hub to check it is clean
2. BBlow on the hub to remove any dust before connecting the syringe or line
3. CRinse the hub with tap water and dry it
4. DScrub the hub with an antiseptic such as chlorhexidine and let it dry

A nurse teaches a patient to use an incentive spirometer. Which statement shows a need for further teaching?

1. A“I will try to hold my breath for a few seconds at the top.”
2. B“I will breathe in slowly and deeply through the mouthpiece.”
3. C“I will blow into it as hard and fast as I can.”
4. D“I will use it several times every hour while awake.”

Pacjent z cewnikiem centralnym nagle odczuwa duszność, ból w klatce piersiowej i spadek SpO₂ podczas usuwania cewnika. Co robi pielęgniarka w pierwszej kolejności?

1. AProsi pacjenta o wolne, głębokie oddechy i kontynuuje
2. BZakrywa miejsce wkłucia, układa pacjenta na lewym boku z głową w dół, podaje tlen i wzywa pomoc
3. CSadza pacjenta w pozycji pionowej i szybko kończy usuwanie cewnika
4. DPrzepłukuje cewnik solą fizjologiczną, aby usunąć ewentualną niedrożność

After the RN taught a patient to inject insulin, an LPN/LVN reports that the patient still cannot draw up the dose correctly. What should happen next?

1. AThe RN reassesses the patient’s learning needs and adjusts the teaching
2. BThe LPN/LVN writes a new teaching plan and evaluates it at the end of the shift
3. CThe nursing assistant shows the patient again at lunch
4. DThe patient is discharged with a leaflet to read at home