Приоритизация и делегирование: лист заданий с ответами

Какую задачу дипломированная медсестра должна оставить за собой, а не делегировать нелицензированному вспомогательному персоналу?

1. AПомощь стабильному пациенту дойти до туалета и обратно
2. BМытьё стабильного пациента
3. CПервичную оценку только что поступившего пациента
4. DИзмерение и запись выпитой и выделенной жидкости

A conscious adult with hypoglycemia can swallow safely. What should the nurse give first?

1. AIV glucose through a new cannula as the first choice for every patient
2. BA large protein meal
3. CA fast-acting carbohydrate by mouth, such as glucose tablets or juice
4. DThe next dose of insulin

Which patient usually fits ESI level 5?

1. AA stable adult who only needs a repeat prescription
2. BAn adult in cardiac arrest
3. CAn adult with chest pain suggesting a heart attack
4. DA stable adult who needs blood tests and an X-ray of the chest

On a postpartum unit, which patient is the most appropriate to assign to an LPN/LVN?

1. ADay 1 after an uncomplicated vaginal birth, stable vital signs
2. BSevere pre-eclampsia on a magnesium sulfate infusion
3. CA new admission transferred from the labor ward with a fever of 38,6 °C
4. DOne hour after birth with heavy bleeding and a boggy uterus

Which patient is at the highest risk of falling?

1. AA 45-year-old with asthma who is alert and independent
2. BA 60-year-old admitted for chest pain that has since been ruled out by tests
3. CA 30-year-old after an appendectomy who walks with steady steps
4. DAn 84-year-old taking a diuretic who has fallen before and gets up at night

A patient on hemodialysis has an arteriovenous fistula in the left arm. Which instruction should the nurse give the nursing assistant?

1. AHelp the patient carry shopping bags on the left arm
2. BKeep the left arm wrapped tightly in a bandage at night
3. CMeasure blood pressure on the left arm only, every 4 hours
4. DDo not measure blood pressure on the left arm

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

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

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