Lembar kerja Prioritas & delegasi dengan jawaban

In US units, which blood urea nitrogen (BUN) result is within the normal adult range?

1. A15 mg/dL
2. B70 mg/dL
3. C45 mg/dL
4. D2 mg/dL

Tugas yang memerlukan pengkajian, pertimbangan keperawatan, atau evaluasi harus:

1. ADiberikan kepada keluarga pasien
2. BDidelegasikan kepada asisten keperawatan yang paling berpengalaman
3. CDilakukan oleh perawat terdaftar
4. DSelalu didelegasikan kepada LPN/LVN

Tugas mana yang harus dipegang sendiri oleh perawat terdaftar dan tidak didelegasikan kepada tenaga asisten tanpa lisensi?

1. APengkajian awal pasien yang baru masuk
2. BMemandikan pasien yang stabil
3. CMembantu pasien yang stabil berjalan ke kamar mandi dan kembali
4. DMengukur dan mencatat asupan dan keluaran cairan

A nasogastric tube has just been placed for feeding. What must happen before the first feed is given?

1. AThe feed is started slowly to see if the patient coughs
2. BThe patient is asked if the tube feels comfortable
3. CThe tube is flushed with a large volume of water
4. DPlacement is confirmed by an approved method

Tugas mana yang harus didelegasikan perawat kepada asisten keperawatan untuk pasien dengan kewaspadaan jatuh?

1. AMembantu pasien ke toilet setiap 2 jam sesuai rencana
2. BMengedukasi keluarga cara mencegah jatuh di rumah
3. CMengkaji dan mencatat skor risiko jatuh pasien setiap pagi
4. DMemutuskan apakah alarm tempat tidur masih diperlukan

A patient has a reddened area on the sacrum that does not blanch when pressed. What is the priority action?

1. ARelieve pressure on the area by changing position regularly
2. BApply a heat pad to the area to increase circulation
3. CMassage the area firmly to improve the blood flow to the skin
4. DKeep the patient lying on the back to protect the area

A patient with a head injury has a pupil on one side that is now large and does not react to light. What should the nurse do?

1. ADocument it, because pupils often differ slightly after a head injury
2. BReport it at once, as it may mean the brain is being compressed
3. CRecheck it at the next routine observation in four hours
4. DDim the room lights so the pupil can get smaller

A patient receiving comfort-focused end-of-life care is distressed by breathlessness. Which approach is most appropriate?

1. AWithhold all opioids because they may slow breathing
2. BStart a series of aggressive tests to find the exact cause of the breathlessness
3. CGive prescribed opioids and use positioning and a fan to relieve breathlessness
4. DLeave the patient alone so they can rest