Phiếu bài tập Ưu tiên và ủy thác công việc có đáp án

What should the nurse try before using physical restraints on a confused patient?

1. AAsking the family to bring restraints from home
2. BUsing restraints at once and removing them later if they turn out not to be needed
3. CRestraining all four limbs to be fully safe
4. DLess restrictive measures, such as more frequent checks or a bed alarm

Which finding is one of the quick SOFA (qSOFA) criteria for possible sepsis?

1. ABlood glucose above 100 mg/dL
2. BHeart rate below 60/min
3. CTemperature below 36,5 °C on one reading
4. DRespiratory rate of 22/min or more

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

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

Which patient on an addiction unit should the nurse see first?

1. ALast drink two days ago; now shaking, sweating, heart rate 124/min and seeing insects
2. BIn recovery for a year; came to the clinic today for a routine check and a repeat prescription
3. CLast drink one week ago; asking about support groups
4. DLast drink this morning; asking when lunch will arrive

A patient with a spinal cord injury at T4 suddenly has a severe headache, flushing above the injury and a blood pressure of 200/110 mmHg. What does the nurse do first?

1. AApply extra blankets to keep the patient warm and calm
2. BSit the patient upright with the legs lowered
3. CGive a warm drink and recheck the blood pressure in an hour
4. DLay the patient flat with the legs raised

Straight after birth, what is the first priority for a healthy-looking newborn?

1. AWeigh and measure the baby on the scale
2. BGive the first bath to remove the blood and vernix
3. CGive the vitamin K injection before anything else is done
4. DDry and warm the baby while checking that it is breathing

During birth, the baby’s head delivers but the shoulders do not follow. What should the nurse do first?

1. AAsk the mother to stop pushing and wait an hour
2. BHelp with the McRoberts position and give suprapubic pressure as directed
3. CPull hard on the baby’s head and neck to free the trapped shoulders quickly
4. DPush firmly on the top of the uterus (fundal pressure)

A patient taking an MAO inhibitor antidepressant is taught about diet. Which statement shows a need for further teaching?

1. A“A sudden severe headache is a warning sign.”
2. B“I will check with the pharmacist before cold remedies.”
3. C“I can still eat aged cheese and cured salami.”
4. D“I will avoid tap beer and red wine.”