Prioritization & delegation worksheet with answers

In priority questions, what does an “unstable” patient mean?

1. AA patient whose condition is changing or hard to predict
2. BA patient who takes more than five different medications
3. CA patient who has a long-term illness such as diabetes
4. DA patient who is anxious and tearful about tomorrow’s surgery

Which finding meets the usual definition of orthostatic hypotension?

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

What is the CIWA scale used to assess?

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

Four hours after thyroid surgery, which patient finding should the nurse act on first?

1. AA voice that is getting hoarser, with new noisy breathing
2. BA request to sit up to drink
3. CPain at the incision of 4/10
4. DA small amount of serous drainage visible on the neck dressing

A patient has a blood pressure of 210/120 mmHg. Which finding would make this a hypertensive emergency?

1. ANew chest pain or confusion suggesting organ damage
2. BForgetting to take the blood pressure tablet this morning
3. CMild anxiety about the high reading on the monitor
4. DA history of high blood pressure for ten years

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

1. A“I will put up no-smoking signs at the front door and in my room.”
2. B“I will keep the oxygen away from the gas stove.”
3. C“I will not use oil-based creams on my face.”
4. D“My husband can smoke in my room if the window is open.”

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

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

A child is admitted with a suspected Wilms tumor (nephroblastoma). Which instruction is most important for all staff?

1. ADo not palpate the abdomen
2. BGive a warm bath with abdominal massage
3. CEncourage the child to play contact sports
4. DMeasure abdominal girth by pressing firmly