Приоритизация и делегирование: лист заданий с ответами

In the ABC framework, which finding is mainly a breathing problem?

1. AA blood glucose of 60 mg/dL (3,3 mmol/L)
2. BShallow breaths with an SpO₂ of 85% on room air
3. CHeart rate 150/min with a low blood pressure and cold skin
4. DStridor caused by a swollen throat

Which capillary refill time is prolonged in an adult?

1. A2 seconds
2. B1 second
3. CLess than 1 second
4. D4 seconds

Which statement about pulse oximetry is correct?

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

Во время внутривенной инфузии антибиотика у пациента появились крапивница, свистящее дыхание и охриплый голос. Что медсестра делает первым?

1. AЗамедляет инфузию вдвое
2. BДокументирует реакцию в карте
3. CДаёт дифенгидрамин внутрь
4. DОстанавливает инфузию

Стабильному взрослому с нормальными жизненными показателями нужно наложить швы на порез руки, ничего больше. Какой уровень ESI подходит?

1. AУровень 4
2. BУровень 2
3. CУровень 3
4. DУровень 5

Two nursing assistants argue loudly at the station about their assignments. What is the charge nurse’s best first step?

1. AMeet both of them privately to hear each side
2. BReport them to human resources at once
3. CChange both of their assignments without any discussion
4. DIgnore it and hope they sort it out

A provider asks a nurse to perform a procedure that is outside the nurse’s scope of practice. What should the nurse do?

1. ADo it, because the provider gave the instruction
2. BDo it just this once and promise the provider not to do it again
3. CAsk a nursing assistant to do it instead
4. DDecline, explain why and suggest who can safely do it

Two patients on the unit have the same surname. What should the nurse do before giving a medication?

1. AAsk the patient, “Are you Mr Smith?” and give the drug once he says yes
2. BUse the room number as the main identifier
3. CCheck two identifiers against the wristband and the medication record
4. DAsk a nursing assistant which patient is which