還有更多這樣的題目挑戰 ›

護理師在為一位穩定的個案準備常規出院衛教時，注意到另一位個案新出現意識混亂、呼吸每分鐘30次，且血氧飽和度從96%降至88%。主治醫師表示40分鐘後開始查房。完成優先處置的敘述。

Drop-down Cloze

選擇作答後，查看答案。

The nurse should first ::선택::assess the deteriorating client and activate the unit rapid-response processfinish the stable client's discharge teachingwait 40 minutes for routine roundsask the confused client to rest and recheck at the end of the shift, then ::선택::cancel all care for both clients for the remainder of the shiftask the unstable client to call if symptoms worsendefer or reassign the routine teaching task for the stable clientsend the stable client home without any discharge education, while ::선택::reporting only the oxygen saturation without contextcommunicating focused SBAR data and reassessing the responseturning off alarms to reduce stimulationdocumenting the change after all scheduled tasks are complete.

護理師應先::선택::評估惡化中的個案並啟動單位快速反應流程完成穩定個案的出院衛教等待40分鐘進行常規查房請意識混亂的個案休息，並於交班結束時再檢查，然後::선택::取消當班剩餘時間兩位個案的所有照護請不穩定的個案若症狀惡化再呼叫延後或重新指派穩定個案的常規衛教工作讓穩定個案在沒有任何出院衛教的情況下返家，同時::선택::僅報告血氧飽和度而無前後脈絡傳達重點式SBAR資料並再評估反應關閉警報以減少刺激在所有排定工作完成後才記錄此變化。

查看答案

相同主題的下一題A nurse in a busy emergency department is triaging five clients who arrive simultaneously.…本題收錄於此題庫[전통+신유형] NCLEX LEVEL UP 패키지KRW 79,000

僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。