Lembar kerja Prioritas & delegasi dengan jawaban

Seorang asisten keperawatan melaporkan empat temuan. Mana yang harus diperiksa perawat lebih dulu?

1. APasien yang tiba-tiba tidak dapat menggerakkan lengan kanannya
2. BPasien yang meminta selimut tambahan
3. CPasien yang ingin menelepon kerabat
4. DPasien yang nampan sarapannya tidak habis

Which laboratory finding is expected in a patient with chronic kidney disease who receives dialysis?

1. AA low serum creatinine
2. BA serum sodium of 160 mEq/L
3. CA platelet count of 900,000/mm³
4. DA raised serum creatinine

Which statement about pulse oximetry is correct?

1. AThe reading is always correct, whatever finger or hand is used
2. BIt shows the patient’s blood glucose
3. CCold fingers or nail polish can give an inaccurate reading
4. DIt measures the carbon dioxide in the blood

A conscious patient with hypoglycemia drank juice 15 minutes ago. The glucose is now 62 mg/dL (3,4 mmol/L). What should the nurse do next?

1. AGive another serving of fast-acting carbohydrate and recheck in 15 minutes
2. BRecord the result and recheck the glucose at the usual time before the evening meal
3. CGive the next scheduled dose of rapid-acting insulin with the meal
4. DWait another hour, because juice can take a long time to work

A nurse teaches a patient who uses home oxygen. Which statement shows a need for further teaching?

1. A“My husband can smoke in my room if the window is open.”
2. B“I will not use oil-based creams on my face.”
3. C“I will keep the oxygen away from the gas stove.”
4. D“I will put up no-smoking signs at the front door and in my room.”

On a postpartum unit, which patient is the most appropriate to assign to an LPN/LVN?

1. ASevere pre-eclampsia on a magnesium sulfate infusion
2. BDay 1 after an uncomplicated vaginal birth, stable vital signs
3. COne hour after birth with heavy bleeding and a boggy uterus
4. DA new admission transferred from the labor ward with a fever of 38,6 °C

A patient has peripheral arterial disease with a non-healing ulcer on the toe. Which advice about leg position is correct?

1. AWrap the legs tightly with compression bandages
2. BKeep the legs level or slightly lowered, not raised
3. CSit with the legs crossed to improve blood flow
4. DKeep the legs raised above the heart as much as possible

On an addiction unit, which patient should the nurse assess first?

1. AAsking for an extra blanket and a hot drink
2. BDrowsy with pinpoint pupils and a respiratory rate of 7/min
3. CYawning, with a runny nose and dilated pupils
4. DAnxious, with goose bumps, stomach cramps and loose stools