Ustalanie priorytetów i delegowanie: karta pracy z odpowiedziami

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. CShort pauses in breathing during normal sleep
4. DSlow, shallow breathing after an opioid overdose

Which patient is unstable?

1. AA patient waiting for a planned hip X-ray
2. BA patient with long-standing arthritis pain of 3/10
3. CA patient with a healing leg wound and normal vital signs this morning
4. DA patient with a new irregular pulse who says they feel dizzy

Which statement about pulse oximetry is correct?

1. AThe reading is always correct, whatever finger or hand is used
2. BIt shows the patient’s blood glucose
3. CIt measures the carbon dioxide in the blood
4. DCold fingers or nail polish can give an inaccurate reading

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

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

An anxious patient is breathing very fast and has tingling fingers. The blood gas shows pH 7,51 and PaCO₂ 29 mmHg (3,9 kPa). What should the nurse do first?

1. AGive IV sodium bicarbonate as soon as it can be found
2. BEncourage the patient to breathe even faster
3. CGive oxygen at the highest flow and leave the room
4. DStay with the patient and coach slow, calm breathing

A patient with a valid do-not-resuscitate order (DNR; called DNACPR in the UK) stops breathing and has no pulse. What should the nurse do?

1. AStart chest compressions but not rescue breaths
2. BStart CPR and stop when the family arrives
3. CCall the cardiac arrest team and let them decide
4. DFollow the DNR order and do not start CPR

Two hours after a femoral cardiac catheterization, the nurse sees blood spreading from the puncture site. What is the first action?

1. AAsk the patient to bend the leg at the hip to stop the bleeding
2. BApply firm, direct pressure just above the puncture site
3. CRaise the head of the bed so the patient can sit up
4. DRemove the dressing and leave the site open to the air

Which finding after a laparoscopic cholecystectomy is expected and needs only reassurance and comfort measures?

1. AYellow skin with dark urine on the second day
2. BRight shoulder pain from the gas used during surgery
3. CA heart rate of 125/min with a falling blood pressure
4. DIncreasing abdominal pain with a temperature of 39 °C