Lembar kerja Prioritas & delegasi dengan jawaban

Dalam sistem triase tiga tingkat, pasien mana yang tergolong gawat darurat?

1. ANyeri dada dengan berkeringat dan sesak napas
2. BPermintaan resep ulang
3. CNyeri perut selama dua hari dengan tanda vital normal
4. DRuam selama tiga hari tanpa demam

Which serum creatinine result suggests reduced kidney function in an adult?

1. A0,8 mg/dL (about 70 µmol/L)
2. B1,0 mg/dL (about 90 µmol/L)
3. C3,5 mg/dL (about 310 µmol/L)
4. D0,7 mg/dL (about 60 µmol/L)

Which resting heart rate is normal for a newborn?

1. A60/min
2. B140/min
3. C210/min
4. D80/min

Which patient is at the highest risk of falling?

1. AA 60-year-old admitted for chest pain that has since been ruled out by tests
2. BA 30-year-old after an appendectomy who walks with steady steps
3. CA 45-year-old with asthma who is alert and independent
4. DAn 84-year-old taking a diuretic who has fallen before and gets up at night

A patient has a serum potassium of 2,9 mEq/L. Which finding should the nurse expect?

1. AMuscle weakness and U waves on the ECG
2. BTall, peaked T waves and muscle twitching
3. CFlushed, warm skin and a slow heart rate
4. DA rise in urine output and thirst only

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

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

Which finding most suggests a tension pneumothorax rather than a simple pneumothorax?

1. AMild breathlessness with reduced breath sounds on one side of the chest only
2. BTrachea shifted away from the affected side, with low blood pressure
3. CSharp chest pain that is worse on deep breathing
4. DA small air leak seen on a routine chest X-ray

Seorang LPN/LVN melaporkan bahwa pasien yang stabil kini mengalami nyeri dada baru. Apa yang harus dilakukan RN?

1. AMengkaji pasien secara langsung dan memutuskan langkah berikutnya
2. BMeminta asisten keperawatan merekam EKG dan menunggu hasilnya
3. CMeminta LPN/LVN menanganinya dan melapor kembali di akhir giliran jaga
4. DMenyuruh LPN/LVN memberikan nitrogliserin bila perlu tanpa pengkajian