Prioritization & delegation worksheet with answers

Which maneuver opens the airway of an unresponsive adult with no suspected spinal injury?

1. ARaising the legs above the heart
2. BJaw thrust without head tilt
3. CHead-tilt, chin-lift
4. DTurning the head sharply to one side

Which pain scale is designed for infants and young children who cannot describe their pain?

1. AThe FLACC scale
2. BThe Glasgow Coma Scale
3. CThe Braden Scale
4. DThe Morse Fall Scale

Which finding meets the usual definition of orthostatic hypotension?

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

A nurse asks a nursing assistant to “assess the patient’s pain and decide if the patient needs more medication”. Which right of delegation is violated?

1. ARight task
2. BRight circumstance
3. CRight supervision and evaluation
4. DRight person

A patient arrives in the recovery room after general anesthesia. What does the nurse assess first?

1. AThe pain score
2. BThe surgical dressing and the drains
3. CUrine output
4. DAirway patency and breathing

In a cardiac arrest on a ward, which action comes first after confirming the patient is unresponsive and not breathing normally?

1. AMeasure the blood pressure
2. BFind the patient’s chart to check the resuscitation status before calling for help
3. CGive two rescue breaths, then check for a pulse for one minute
4. DCall for help and start chest compressions

A patient with heart failure is short of breath with crackles in both lungs. Which order of actions is correct?

1. ALay the patient flat to rest, then start the IV maintenance fluids
2. BGive the scheduled oral medicines first, then sit the patient up
3. CWeigh the patient first, then reassess the breathing in four hours
4. DSit up, give oxygen as prescribed, then call the provider

A patient rescued from a house fire has burns to the face, singed nasal hair and a hoarse voice. What is the priority?

1. AGiving pain relief
2. BStarting IV fluid resuscitation calculated from the burn size
3. CProtecting the airway, preparing for early airway support
4. DCleaning and dressing the facial burns