Lembar kerja Prioritas & delegasi dengan jawaban

A patient’s respiratory rate is 30/min at rest. How should the nurse classify this finding in an adult?

1. ASlow, and expected while the patient is asleep
2. BAbnormally fast and needing assessment
3. CWithin the normal adult range
4. DNormal after a meal

A patient’s platelet count is 18,000/mm³ (18 × 10⁹/L). Which risk is the nursing priority?

1. ABleeding
2. BFluid overload
3. CInfection
4. DBlood clots

Which finding in an infant is a sign of breathing difficulty?

1. AA strong cry
2. BNasal flaring
3. CPink, warm hands and feet
4. DWet diapers every few hours

Seorang perawat meminta asisten keperawatan menggunakan lift mekanis. Asisten mengatakan belum pernah dilatih menggunakannya. Hak pendelegasian mana yang dilanggar bila perawat berkeras?

1. AOrang yang benar
2. BTugas yang benar
3. CArahan dan komunikasi yang benar
4. DPengawasan dan evaluasi yang benar

A nurse teaches a patient who has started warfarin. Which statement shows a need for further teaching?

1. A“I will tell my dentist and pharmacist that I take warfarin.”
2. B“I will keep my INR blood test appointments.”
3. C“I will use a soft toothbrush.”
4. D“If I miss a dose, I will take two the next day.”

After a hip replacement, a patient has sudden severe hip pain, and the operated leg looks shorter and turned. What should the nurse suspect?

1. AA pressure injury on the heel
2. BDislocation of the new hip
3. CA urinary tract infection
4. DNormal pain after surgery

A patient with known abdominal aortic aneurysm suddenly has severe back pain, a pulsing mass in the abdomen and a falling blood pressure. What should the nurse do?

1. APalpate the mass firmly to check its size and spread
2. BGive an oral analgesic and reassess the patient in about one hour
3. CCall for emergency help at once and prepare for urgent surgery
4. DEncourage the patient to walk to ease the back pain

Di unit jantung, pasien mana yang harus ditemui perawat lebih dulu?

1. APasien yang diminta berpuasa sebelum pemindaian besok
2. BPasien gagal jantung yang berat badannya naik 0,3 kg sejak kemarin
3. CPasien fibrilasi atrium dengan denyut jantung 88/menit dan tidak teratur, seperti sebelumnya
4. DPasien yang mengonsumsi digoksin dengan nadi 48/menit, mual, dan kalium 3,0 mEq/L