Lembar kerja Keperawatan klinis dengan jawaban

Area kemerahan yang tidak memucat saat ditekan pada kulit utuh di atas sakrum diklasifikasikan sebagai kategori luka tekan yang mana?

1. AKategori 1
2. BKategori 4
3. CKategori 2
4. DKategori 3

A pneumothorax is:

1. AA blood clot in the lung arteries
2. BFluid in the alveoli, usually from heart failure
3. CAir in the pleural space, causing the lung to collapse
4. DAn infection of the lung tissue, usually caused by bacteria

Mengapa pasien stroke harus menjalani skrining menelan sebelum diberi makanan, cairan, atau obat lewat mulut?

1. AUntuk mencegah luka tekan
2. BUntuk memeriksa kadar glukosa darahnya
3. CUntuk mengukur tekanan darahnya
4. DUntuk mengurangi risiko aspirasi

Which pattern is typical of relapsing–remitting multiple sclerosis?

1. ASudden severe headache with neck stiffness
2. BAttacks of symptoms, such as visual loss or numbness, that improve between relapses
3. CConstant weakness that starts in the feet and spreads upwards after a viral illness
4. DA single stroke that leaves permanent weakness

During a vesicant chemotherapy infusion, the patient reports burning and swelling at the cannula site. What should the nurse do first?

1. AApply a warm pack and continue the infusion
2. BFlush the cannula hard with saline
3. CIncrease the rate so that the infusion finishes as quickly as possible
4. DStop the infusion straight away and follow the extravasation protocol

A patient on haemodialysis has an arteriovenous fistula in the left arm. Which nursing care is correct?

1. AUse the fistula arm for routine IV cannulas
2. BApply a tight bandage over the fistula at night to protect it
3. CKeep the arm raised and still at all times
4. DAvoid blood pressure readings and blood samples on that arm

A nurse teaches a patient with hypertension about their medicines. Which statement shows a need for further teaching?

1. A"I'll keep taking my tablets even if I feel well."
2. B"I'll stop my tablets once my readings are normal."
3. C"I'll get up slowly from sitting."
4. D"I'll have my blood pressure checked regularly."

A drowsy patient in recovery is making snoring sounds and the SpO₂ is falling. What is the first action?

1. ALie the patient face down
2. BOpen the airway with a head tilt–chin lift or jaw thrust
3. CWait for the patient to wake up fully
4. DGive sips of oral fluid to clear the throat and wake them