ใบงาน การจัดลำดับความสำคัญและการมอบหมายงาน พร้อมเฉลย

What is the CIWA scale used to assess?

1. AThe severity of alcohol withdrawal
2. BThe risk of a pressure injury
3. CThe severity of a newborn’s jaundice
4. DThe depth of a burn wound

Which symptoms are classic signs of digoxin toxicity?

1. AA rash, high fever and swollen lymph nodes in the neck
2. BHair loss and weight gain
3. CNausea, poor appetite and yellow-green visual halos
4. DHigh blood sugar and increased thirst

ข้อสังเกตในผู้ใหญ่ข้อใดที่พยาบาลควรดำเนินการก่อน?

1. Aอุณหภูมิ 37.8 °C (100 °F)
2. Bความดันโลหิต 138/88 mmHg และรู้สึกตัวดี
3. Cอัตราการหายใจ 8 ครั้ง/นาทีและง่วงซึม
4. Dชีพจร 98 ครั้ง/นาที

A nurse teaches a patient who uses crutches. Which statement shows a need for further teaching?

1. A“I will take my weight on my hands, not on my armpits.”
2. B“I will keep the crutch tips in good condition.”
3. C“I will remove loose rugs from the floor at home.”
4. D“I will lean on the crutch pads under my arms to rest.”

A patient receiving chemotherapy has a temperature of 38.3 °C and a very low neutrophil count. What should the nurse do?

1. ARecheck the temperature in four hours before telling anyone
2. BReport it at once, because cultures and antibiotics are needed quickly
3. CGive a cool shower and offer extra fluids, then wait and see what happens
4. DDocument the reading and mention it at the next handover

Before giving a scheduled dose of metoprolol, which assessment is most important?

1. ABowel sounds and urine color
2. BBlood glucose and weight
3. CApical pulse and blood pressure
4. DTemperature and the latest pain score

Which nursing approach may raise intracranial pressure in a patient with a head injury?

1. AKeeping the room calm and quiet
2. BKeeping the head in line with the body
3. CSpacing out care with rest periods in between activities
4. DDoing suctioning, turning and bathing all at the same time

Six hours after surgery, a patient has not passed urine, feels the urge to go and has a firm swelling above the pubic bone. What is the most likely problem?

1. AAcute kidney injury with no urine made
2. BDehydration from fasting before surgery
3. CA normal effect of the anesthetic
4. DUrinary retention