Робочий аркуш «Пріоритезація та делегування» з відповідями

Why may a full-thickness burn feel painless at its center?

1. AThe patient has been given too much fluid
2. BThe burn only affects the thin surface layer of the skin
3. CThe burn has already fully healed
4. DThe nerve endings in the skin have been destroyed

Which task should the registered nurse not delegate to a nursing assistant?

1. AMaking an occupied bed
2. BGiving a bed bath to a stable patient
3. CWalking a stable patient up and down the corridor after lunch
4. DEvaluating whether the patient understood discharge teaching

Which patient usually fits ESI level 5?

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

Which action helps prevent a catheter-associated urinary tract infection?

1. ALeaving the catheter in place longer than needed
2. BKeeping the drainage bag below the level of the bladder
3. CRaising the drainage bag above the bladder when walking
4. DDisconnecting the bag every shift to empty it

Which two patients can most safely share a room?

1. AA patient with influenza and a patient with COPD
2. BA patient with MRSA in a wound and a patient after surgery
3. CA patient with chickenpox and a patient on chemotherapy
4. DTwo patients who both have C. difficile infection

Which patient is at the highest risk of falling?

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

Which patient finding after a total knee replacement needs the nurse’s action first?

1. ASudden calf pain and swelling in the operated leg, with new breathlessness
2. BPain of 4/10 when the physiotherapist bends the knee during the morning session
3. CA small amount of dried blood on the dressing
4. DAsks for an ice pack to help with swelling around the knee

Медсестра вважає призначену дозу небезпечною. Лікар каже дати її все одно. Що має зробити медсестра?

1. AДати дозу, бо тепер відповідальність за неї несе лікар
2. BУтримати дозу та ескалувати через ланцюг командування
3. CДати половину дози як компроміс і задокументувати причину
4. DТихо пропустити дозу й нічого не казати, щоб уникнути конфлікту