ใบงาน การจัดลำดับความสำคัญและการมอบหมายงาน พร้อมเฉลย

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

Which term describes a patient who is unable to understand and decide about their own care?

1. ALacking decision-making capacity
2. BExercising autonomy
3. CFully competent
4. DProviding valid informed consent

In a three-level triage system, what does “urgent” mean?

1. ASerious but stable for now, and needs care soon
2. BAlready deceased on arrival
3. CLife-threatening and needs care immediately
4. DMinor, and can safely wait for several hours

A nurse teaches a patient who has started warfarin. Which statement shows a need for further teaching?

1. A“I will keep my INR blood test appointments.”
2. B“I will tell my dentist and pharmacist that I take warfarin.”
3. C“I will use a soft toothbrush.”
4. D“If I miss a dose, I will take two the next day.”

A patient is raising his voice, pacing and clenching his fists. What should the nurse do first?

1. ASpeak calmly, keep a safe distance and invite him to talk about what is wrong
2. BStand very close to him and tell him firmly and loudly to sit down and be quiet
3. CTurn away and ignore the behavior
4. DApply physical restraints at once

A patient has a tonic-clonic seizure in bed. What should the nurse do first?

1. APlace a tongue depressor between the teeth
2. BHold the arms and legs down firmly to stop the jerking movements quickly
3. CProtect the head and turn the patient on their side when possible
4. DGive a drink of water to help the patient wake

An 85-year-old resident becomes newly confused and is falling, but has no fever. Which cause should the nurse consider first?

1. ABoredom from not having enough activities
2. BAn infection, such as a urinary tract infection, presenting atypically
3. CNormal aging that needs no assessment
4. DA sudden worsening of long-standing dementia that needs no tests

A patient on peritoneal dialysis has cloudy fluid draining out and abdominal pain. What does this most likely mean?

1. AConstipation that will settle with a laxative later today or tomorrow
2. BToo much fluid left in the abdomen after the drain
3. CPeritonitis, which needs prompt reporting and a fluid sample
4. DA normal finding at the end of each exchange