Prioritization & delegation worksheet with answers

When is the Apgar score usually assessed?

1. ABefore the baby is born
2. BAt the first postnatal clinic visit
3. COnly at 24 hours after birth
4. DAt 1 and 5 minutes after birth

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

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

Which patient is the most stable?

1. AA patient two days after knee surgery with pain of 3/10 and normal vital signs
2. BA patient who has become newly confused
3. CA patient with new chest pain
4. DA patient whose blood pressure has fallen from 132/80 to 90/56 mmHg

On a mixed medical unit, which patient should the nurse see first?

1. AA patient with depression who has given away his belongings and has a suicide plan
2. BA patient asking for written information about tomorrow’s discharge
3. CA patient with a mild tension headache who is asking for acetaminophen
4. DA patient with hypertension whose blood pressure is 136/84 mmHg

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

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

A patient taking lithium has vomiting, diarrhea and a new coarse tremor. What should the nurse do?

1. AReassure the patient that a coarse tremor is expected at first
2. BHold the next dose and report for an urgent lithium level
3. CEncourage the patient to cut down on salt and fluids
4. DGive the dose with food to reduce the stomach upset

Which nursing approach may raise intracranial pressure in a patient with a head injury?

1. AKeeping the room calm and quiet
2. BKeeping the head in line with the body
3. CDoing suctioning, turning and bathing all at the same time
4. DSpacing out care with rest periods in between activities

A patient with a new tracheostomy is coughing, has noisy breathing and an SpO₂ that has fallen to 86%. What is the first action?

1. AGive a nebulized bronchodilator
2. BSuction the tracheostomy
3. CDocument the SpO₂ and recheck in 30 minutes
4. DChange the tracheostomy ties