Ustalanie priorytetów i delegowanie: karta pracy z odpowiedziami

Which laboratory finding is expected in a patient with chronic kidney disease who receives dialysis?

1. AA low serum creatinine
2. BA platelet count of 900,000/mm³
3. CA serum sodium of 160 mEq/L
4. DA raised serum creatinine

What should the nurse try before using physical restraints on a confused patient?

1. AUsing restraints at once and removing them later if they turn out not to be needed
2. BAsking the family to bring restraints from home
3. CLess restrictive measures, such as more frequent checks or a bed alarm
4. DRestraining all four limbs to be fully safe

Które stwierdzenie najlepiej opisuje delegowanie w pielęgniarstwie?

1. APrzekazanie kompetentnej osobie uprawnień do wybranego zadania, przy czym pielęgniarka pozostaje odpowiedzialna
2. BPoproszenie lekarza o przejęcie zadania, na które pielęgniarka nie ma czasu
3. CPrzekazanie innej osobie całej odpowiedzialności za pacjenta
4. DOdmowa wykonania zadania, ponieważ wykracza poza własną rolę

A nursing assistant offers to suction a patient’s new tracheostomy. Which response from the RN is best?

1. A“Thank you, please suction him as needed and tell me how it went.”
2. B“Leave the suctioning until the next shift arrives.”
3. C“Ask the patient’s family to do the suctioning today.”
4. D“Suctioning a new tracheostomy is my task; I will do it myself.”

A patient uses patient-controlled analgesia (PCA) after surgery. Which statement by a family member shows a need for further teaching?

1. A“The pump has limits set by the nurse so she cannot get too much at once.”
2. B“I will press the button for her while she is asleep so she stays comfortable.”
3. C“Only she should press the button when she needs pain relief.”
4. D“I will tell the nurse if she becomes very sleepy or hard to wake.”

Which SBAR recommendation is the clearest?

1. A“He seems a bit off tonight, so maybe you could come up and do something about it.”
2. B“I just wanted to let you know about him.”
3. C“I would like you to see him within 15 minutes and consider a fluid bolus.”
4. D“I will keep watching him and call again tomorrow.”

Four laboratory results come back at once. Which one should the nurse report first?

1. ACreatinine 1,3 mg/dL in an older adult, unchanged from last week
2. BPotassium 3,4 mEq/L in a patient on a diuretic
3. CHemoglobin 6,5 g/dL (65 g/L) in a patient with a GI bleed
4. DGlucose 180 mg/dL after a meal in a patient with diabetes

A nurse teaches a patient to inject enoxaparin at home. Which statement shows a need for further teaching?

1. A“I will rub the area after the injection to help it absorb.”
2. B“I will tell my doctor if I notice unusual bruising or bleeding.”
3. C“I will change the injection site each time.”
4. D“I will inject into the fat of my abdomen, away from the navel.”