Lembar kerja Prioritas & delegasi dengan jawaban

Which finding should a nursing assistant report to the nurse at once?

1. AA patient who wants to shower in the evening
2. BA pulse of 42/min in a patient whose usual pulse is 76/min
3. CA patient who would like tea instead of coffee
4. DA patient whose weight is unchanged from yesterday

In the ABC framework, which finding is mainly a breathing problem?

1. AA blood glucose of 60 mg/dL (3,3 mmol/L)
2. BStridor caused by a swollen throat
3. CShallow breaths with an SpO₂ of 85% on room air
4. DHeart rate 150/min with a low blood pressure and cold skin

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

Five days after starting heparin, a patient’s platelet count has fallen by more than half. What should the nurse suspect?

1. AVitamin K deficiency
2. BIron deficiency anemia
3. CAn expected effect that needs no action
4. DHeparin-induced thrombocytopenia

A nurse takes a telephone order from a provider. What must the nurse do?

1. AWrite the order down and read it back to the provider to confirm it
2. BAsk the ward clerk to take the order on the nurse’s behalf instead
3. CCarry out the order first and ask the provider to confirm it later
4. DRemember the order and write it in the chart at the end of the shift

Pernyataan mana yang menunjukkan pemahaman yang benar tentang akuntabilitas dalam pendelegasian?

1. A"Jika tugas itu salah, hanya asistennya yang bertanggung jawab."
2. B"Asisten keperawatan bertanggung jawab atas apakah tugas itu tepat didelegasikan."
3. C"Saya tetap bertanggung jawab atas keputusan mendelegasikan dan menindaklanjuti hasilnya."
4. D"Begitu saya mendelegasikan suatu tugas, itu bukan lagi urusan saya."

Which patient finding after a total knee replacement needs the nurse’s action first?

1. AAsks for an ice pack to help with swelling around the knee
2. BSudden calf pain and swelling in the operated leg, with new breathlessness
3. CPain of 4/10 when the physiotherapist bends the knee during the morning session
4. DA small amount of dried blood on the dressing

After handover on a medical unit, which patient should the nurse see first?

1. ADay 2 after a hernia repair, pain 6/10, oral analgesic due in 20 minutes, wants it now
2. BPneumonia on 2 L/min oxygen, SpO₂ 93%, talking in full sentences
3. CNew atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy
4. DDeep vein thrombosis on a heparin infusion, aPTT in the target range