优先排序与委派练习卷（附答案）

Which finding meets the usual definition of orthostatic hypotension?

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

成人的哪项发现是护士应首先处理的？

1. A血压 138/88 mmHg，完全清醒
2. B体温 37.8 °C（100 °F）
3. C心率 98 次/分
4. D呼吸频率 8 次/分，嗜睡

哪位患者最稳定？

1. A血压从 132/80 降至 90/56 mmHg 的患者
2. B新发胸痛的患者
3. C新出现意识模糊的患者
4. D膝关节手术后两天，疼痛 3/10，生命体征正常的患者

Which infant with gastroenteritis should the nurse see first?

1. ALethargic, sunken fontanel, no wet diaper for 8 hours
2. BTwo loose stools today, feeding well
3. CAlert, crying with tears, had a wet diaper an hour ago
4. DMild diaper rash, otherwise playful

A patient has a serum potassium of 6.8 mEq/L. Which action comes first?

1. AEncourage foods high in potassium
2. BPlace the patient on a cardiac monitor
3. CGive the patient’s scheduled potassium supplement
4. DRecheck the level next week

After a hip replacement using a posterior approach, which statement shows a need for further teaching?

1. A“I will keep a pillow between my knees when I lie on my side in bed.”
2. B“I will use a raised toilet seat at home.”
3. C“I will not bend my hip past 90 degrees.”
4. D“I will cross my legs when I sit, so I am more comfortable.”

On a cardiac step-down unit, which patient should the nurse assess first?

1. AHeart failure, weight up 0.5 kg since yesterday, no breathlessness at rest
2. BSix hours after a coronary stent, new chest pain with ST elevation on the monitor
3. CDay 2 after a pacemaker insertion, asking when the wound dressing will be changed
4. DAtrial fibrillation on warfarin with an INR of 2.6 this morning

哪项任务最适合 RN 亲自完成，而不是委派给护理助理？

1. A手术后第三天带稳定的患者在走廊里散步
2. B手术后第一次扶患者下床
3. C协助患者进行口腔护理
4. D每天早晨为心力衰竭患者称体重