Prioritization & delegation worksheet with answers

Which finding in an infant is a sign of breathing difficulty?

1. AA strong cry
2. BWet diapers every few hours
3. CNasal flaring
4. DPink, warm hands and feet

In the ABC framework, which problem is a circulation problem?

1. AAnxiety
2. BStridor
3. CUncontrolled bleeding
4. DA respiratory rate of 32/min

In stroke care, what does the “last known well” time mean?

1. AThe time of the patient’s last meal
2. BThe last time the patient was seen without stroke symptoms
3. CThe time the patient arrived at the hospital and was triaged
4. DThe time the first symptom was noticed by a stranger

A nurse sees a nursing assistant measuring a blood pressure with a cuff that is clearly too small. What should the nurse do?

1. AMention it later at the assistant’s next annual appraisal
2. BIgnore it, since one high reading will not matter
3. CRemove the assistant from patient care for the day
4. DStep in now, correct the technique tactfully and recheck

A patient has a reddened area on the sacrum that does not blanch when pressed. What is the priority action?

1. ARelieve pressure on the area by changing position regularly
2. BApply a heat pad to the area to increase circulation
3. CMassage the area firmly to improve the blood flow to the skin
4. DKeep the patient lying on the back to protect the area

A patient receiving IV magnesium sulfate for pre-eclampsia has absent knee reflexes and a respiratory rate of 10/min. What does the nurse do first?

1. AIncrease the infusion to prevent a seizure
2. BTurn the patient onto her back and recheck later
3. CGive oral fluids to help clear the drug faster
4. DStop the magnesium infusion and call for help

A patient at 34 weeks of pregnancy has painless, bright red vaginal bleeding. Which action should the nurse avoid?

1. AMeasuring the blood pressure and pulse
2. BA vaginal examination
3. CMonitoring the fetal heart rate
4. DWeighing the pads to estimate blood loss

A 2-month-old infant has a spiral fracture of the femur. The parents say the baby rolled off the sofa. What should the nurse recognize?

1. AInfants of this age often roll off furniture and break bones in this way
2. BA spiral fracture in an infant is always caused by birth trauma
3. CThe injury does not fit the infant’s development, so possible abuse must be reported
4. DNo further action is needed once the fracture is treated