Приоритизация и делегирование: лист заданий с ответами

A patient has a Glasgow Coma Scale score of 8. What is the main concern?

1. AThe patient can safely eat and drink without help
2. BThe patient may not be able to protect the airway
3. CThe patient is fully alert and oriented
4. DThe patient only has a mild headache

Кто в большинстве учреждений проводит триаж вновь прибывших в отделении неотложной помощи?

1. AСекретарь отделения
2. BLPN/LVN без участия RN
3. CПомощник медсестры
4. DДипломированная медсестра (RN)

In the Emergency Severity Index (ESI), which patient fits level 2?

1. AA stable patient who needs no resources
2. BA high-risk situation, new confusion, or severe pain or distress
3. CA patient who needs an immediate life-saving intervention to survive
4. DA stable patient who needs one resource

Медсестра делегирует измерение глюкозы крови обученному помощнику, но никогда не спрашивает результат. Какое «правильное» делегирования отсутствует?

1. AПравильный человек для задачи
2. BПравильная задача для обстановки
3. CПравильные обстоятельства
4. DПравильный надзор и оценка

Which action helps prevent a catheter-associated urinary tract infection?

1. ARaising the drainage bag above the bladder when walking
2. BLeaving the catheter in place longer than needed
3. CKeeping the drainage bag below the level of the bladder
4. DDisconnecting the bag every shift to empty it

A patient with severe neutropenia needs a room. Which roommate is the safest choice?

1. AA patient with C. difficile diarrhea
2. BA patient with an infected, draining leg wound
3. CA patient after a knee replacement with no signs of infection
4. DA patient with influenza

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

1. AAbility to feed themselves
2. BBowel sounds in all four abdominal quadrants
3. CSkin over the sacrum and heels
4. DBreathing effort and ability to cough

On a cardiac step-down unit, which patient should the nurse assess first?

1. ASix hours after a coronary stent, new chest pain with ST elevation on the monitor
2. BDay 2 after a pacemaker insertion, asking when the wound dressing will be changed
3. CHeart failure, weight up 0,5 kg since yesterday, no breathlessness at rest
4. DAtrial fibrillation on warfarin with an INR of 2,6 this morning