Приоритизация и делегирование: лист заданий с ответами

What are Kussmaul respirations?

1. ASlow, shallow breathing after an opioid overdose
2. BShort pauses in breathing during normal sleep
3. CDeep, rapid breathing seen in metabolic acidosis such as DKA
4. DNoisy, high-pitched breathing caused by a blocked upper airway

Which finding in an infant is a sign of breathing difficulty?

1. ANasal flaring
2. BA strong cry
3. CPink, warm hands and feet
4. DWet diapers every few hours

Which task is appropriate to delegate to a nursing assistant for an immobile but stable patient?

1. APlanning the patient’s skin care
2. BChoosing which wound dressing to use
3. CDeciding whether a pressure injury has got worse since yesterday
4. DTurning and repositioning the patient every 2 hours

Which infant with gastroenteritis should the nurse see first?

1. ALethargic, sunken fontanel, no wet diaper for 8 hours
2. BAlert, crying with tears, had a wet diaper an hour ago
3. CMild diaper rash, otherwise playful
4. DTwo loose stools today, feeding well

A patient on a nasal cannula at 6 L/min still has a low SpO₂. What should the nurse do?

1. ARecheck the SpO₂ at the next routine set of observations in four hours
2. BRemove the oxygen to see if the SpO₂ changes
3. CReport it, because a different oxygen device is likely to be needed
4. DTurn the nasal cannula up to 15 L/min

A patient on a continuous IV heparin infusion has new black, tarry stools and an aPTT well above the target range. What should the nurse do first?

1. AStop the heparin infusion and inform the provider
2. BOffer an iron-rich meal to replace the lost blood
3. CCheck the pump rate and leave the infusion running
4. DGive a dose of vitamin K by mouth

О каком пациенте медсестре следует в первую очередь сообщить бригаде быстрого реагирования?

1. AПациент с целлюлитом с температурой 38,1 °C при остальных нормальных жизненных показателях
2. BПациент с известной гипертензией, у которого давление 152/94 mmHg и который чувствует себя хорошо
3. CПациент после операции на колене с болью 6/10 и нормальными жизненными показателями
4. DПациент с инфекцией мочевых путей, у которого новая спутанность, частота дыхания 26/мин и систолическое давление 94 mmHg

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