Lembar kerja Prioritas & delegasi dengan jawaban

Which blood pressure in an adult suggests hypotension?

1. A126/82 mmHg
2. B118/76 mmHg
3. C110/70 mmHg
4. D82/48 mmHg

Which three things does START triage check in a non-walking adult?

1. AAirway, blood glucose and pupils
2. BPain score, mobility and age
3. CRespirations, perfusion and mental status
4. DPulse, blood pressure and body temperature

An adult without lung disease is breathing room air. Which SpO₂ reading needs action?

1. A96%
2. B97%
3. C89%
4. D99%

A nurse has called the rapid response team for a deteriorating patient. What should the nurse do while waiting for the team?

1. AGo to the station to finish documentation for other patients
2. BStay with the patient, give oxygen as prescribed and have recent vital signs ready
3. CGive a dose of every as-needed medication on the chart
4. DLeave the patient for a few minutes to find the relatives and explain what is happening

Seorang perawat melihat asisten keperawatan mengukur tekanan darah dengan manset yang jelas terlalu kecil. Apa yang harus dilakukan perawat?

1. AMengabaikannya, karena satu pembacaan tinggi tidak akan berarti
2. BMencopot asisten dari perawatan pasien untuk hari itu
3. CSegera turun tangan, mengoreksi teknik dengan bijaksana, dan mengukur ulang
4. DMenyebutkannya nanti pada penilaian tahunan asisten berikutnya

An Rh-negative mother has just given birth to an Rh-positive baby. What does the nurse expect to give the mother?

1. ARh immunoglobulin within 72 hours
2. BVitamin K to the mother
3. CNo treatment is needed
4. DA dose of the hepatitis B vaccine instead

During JumpSTART triage, a child is not breathing after the airway is opened but has a palpable pulse. What is the next step?

1. ATag the child black at once and move on to the next victim
2. BTag the child green and return to them after the others
3. CGive five rescue breaths; if breathing starts, tag the child red
4. DStart full CPR on the child and stay with them until more help arrives

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. BDay 2 after a pacemaker insertion, asking when the wound dressing will be changed
3. CAtrial fibrillation on warfarin with an INR of 2,6 this morning
4. DSix hours after a coronary stent, new chest pain with ST elevation on the monitor