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

Which finding should a nursing assistant report to the nurse at once?

1. AA pulse of 42/min in a patient whose usual pulse is 76/min
2. BA patient who would like tea instead of coffee
3. CA patient who wants to shower in the evening
4. DA patient whose weight is unchanged from yesterday

Which statement about the nursing process is correct when setting priorities?

1. AAssessment comes first, because the other steps depend on it
2. BEvaluation comes first, before any patient data have been collected
3. CPlanning comes first, before seeing the patient
4. DImplementation comes first, so care starts quickly

Which finding meets the usual definition of orthostatic hypotension?

1. ABlood pressure is the same lying and standing
2. BSystolic pressure rises by 20 mmHg or more within 3 minutes of standing up
3. CSystolic pressure falls by 20 mmHg or more within 3 minutes of standing
4. DHeart rate falls by 5/min after lying down

During an IV vancomycin infusion, a patient develops flushing and itching of the face and neck. What should the nurse do first?

1. AApply a warm compress to the face and neck
2. BStop or slow the infusion and inform the provider
3. CSpeed up the infusion to finish it quickly
4. DIgnore it, because flushing is always harmless and passes

Which patient is most suitable for the nurse to assign to a nurse who has just finished orientation?

1. AA patient with a new tracheostomy who needs frequent suctioning
2. BA patient on a continuous heparin infusion with rising aPTT values
3. CA patient with sepsis whose blood pressure is falling
4. DA patient with stable cellulitis on scheduled IV antibiotics

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“If I miss a dose, I will take two the next day.”
3. C“I will use a soft toothbrush.”
4. D“I will tell my dentist and pharmacist that I take warfarin.”

A patient with COPD on 2 L/min oxygen becomes drowsy and hard to wake. The SpO₂ is 93%. What is the priority?

1. AIncrease the oxygen to 6 L/min so that the saturation goes even higher than now
2. BAssess breathing and escalate for a blood gas, as carbon dioxide may be rising
3. CLet the patient sleep, because the saturation is above target
4. DGive the as-needed sedative so the patient rests comfortably

Một người bệnh suy tim khó thở với ran nổ ở cả hai phổi. Thứ tự hành động nào đúng?

1. ACho người bệnh nằm phẳng nghỉ, rồi bắt đầu dịch duy trì tĩnh mạch
2. BCho các thuốc uống theo lịch trước, rồi cho ngồi dậy
3. CCho ngồi dậy, cho thở oxy theo y lệnh, rồi gọi người có thẩm quyền
4. DCân người bệnh trước, rồi đánh giá lại hô hấp sau bốn giờ