Ustalanie priorytetów i delegowanie: karta pracy z odpowiedziami

What does the Morse Fall Scale measure?

1. AA patient’s skin integrity
2. BA patient’s risk of falling
3. CA patient’s nutrition status
4. DA patient’s pain level

W schemacie ABC służącym do ustalania priorytetów pielęgniarskich, która potrzeba jest zaspokajana w pierwszej kolejności?

1. ABól
2. BDrożność dróg oddechowych (Airway)
3. COddychanie (Breathing)
4. DKrążenie (Circulation)

Which phrase in a question usually signals a priority question?

1. A“Which bone is found in the forearm?”
2. B“Which term means inflammation of the liver?”
3. C“Which action should the nurse take first?”
4. D“Which statement describes this drug’s class?”

A conscious patient with hypoglycemia drank juice 15 minutes ago. The glucose is now 62 mg/dL (3,4 mmol/L). What should the nurse do next?

1. AWait another hour, because juice can take a long time to work
2. BRecord the result and recheck the glucose at the usual time before the evening meal
3. CGive the next scheduled dose of rapid-acting insulin with the meal
4. DGive another serving of fast-acting carbohydrate and recheck in 15 minutes

An arterial blood gas shows pH 7,28, PaCO₂ 40 mmHg (5,3 kPa) and HCO₃⁻ 16 mEq/L (mmol/L). How should the nurse interpret it?

1. ARespiratory alkalosis
2. BRespiratory acidosis
3. CMetabolic acidosis
4. DMetabolic alkalosis

Monitor kardiologiczny pokazuje u pacjenta linię płaską (asystolię), ale pacjent siedzi i rozmawia. Co robi pielęgniarka w pierwszej kolejności?

1. ASprawdza pacjenta i przewody elektrod
2. BPrzygotowuje defibrylator do wykonania wstrząsu
3. CNatychmiast rozpoczyna uciskanie klatki piersiowej
4. DWzywa zespół resuscytacyjny

After surgery, a patient who has taken long-term steroids becomes hypotensive and weak, and the blood pressure does not rise with IV fluids. Which problem should the nurse suspect?

1. AAdrenal crisis from steroid withdrawal
2. BFluid overload from too much IV fluid
3. CAn allergic reaction to the anesthetic
4. DNormal tiredness after anesthesia

A patient has a chest drain for a pneumothorax. The nurse sees constant bubbling in the water-seal chamber. What does this most likely mean?

1. AThe lung has fully re-expanded, so the drain is ready to come out
2. BThe suction is set too low and needs to be turned up
3. CAn air leak in the patient or the system that needs checking
4. DThe drain is working normally and no action is needed