Lembar kerja Prioritas & delegasi dengan jawaban

Which finding meets the usual definition of orthostatic hypotension?

1. ASystolic pressure falls by 20 mmHg or more within 3 minutes of standing
2. BHeart rate falls by 5/min after lying down
3. CBlood pressure is the same lying and standing
4. DSystolic pressure rises by 20 mmHg or more within 3 minutes of standing up

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

1. AMembantu pasien yang stabil berjalan ke kamar mandi dan kembali
2. BMemandikan pasien yang stabil
3. CMengukur dan mencatat asupan dan keluaran cairan
4. DPengkajian awal pasien yang baru masuk

Which pain scale is designed for infants and young children who cannot describe their pain?

1. AThe Braden Scale
2. BThe Morse Fall Scale
3. CThe Glasgow Coma Scale
4. DThe FLACC scale

Seorang asisten keperawatan melaporkan empat pasien. Laporan mana yang perlu diperhatikan perawat lebih dulu?

1. APasien meminta bantal tambahan
2. BPasien mengeluarkan 300 mL urine dalam 6 jam terakhir
3. CPasien satu hari setelah operasi abdomen tiba-tiba gelisah dan denyut jantungnya 124/menit
4. DPasien PPOK memiliki SpO₂ 90% saat istirahat, sesuai dengan nilai biasanya

Seorang dewasa stabil dengan tanda vital normal mengalami luka sayat di tangan yang memerlukan jahitan dan tidak ada lagi yang lain. ESI level berapa yang sesuai?

1. ALevel 3
2. BLevel 2
3. CLevel 4
4. DLevel 5

One day after surgery, a patient walked safely with the RN this morning. The RN now asks a nursing assistant to walk her again. Which instruction is most important?

1. A“Try to finish the walk before the lunch trays arrive.”
2. B“Walk her to the end of the corridor and back twice before lunch.”
3. C“Make sure she wears her own slippers if she has them.”
4. D“Stop and call me at once if she feels dizzy or short of breath.”

After the RN taught a patient to inject insulin, an LPN/LVN reports that the patient still cannot draw up the dose correctly. What should happen next?

1. AThe RN reassesses the patient’s learning needs and adjusts the teaching
2. BThe nursing assistant shows the patient again at lunch
3. CThe LPN/LVN writes a new teaching plan and evaluates it at the end of the shift
4. DThe patient is discharged with a leaflet to read at home

A patient with raised intracranial pressure is being nursed on the ward. Which position is best?

1. AHead of the bed at about 30 degrees with the neck straight
2. BSitting forward with the chin on the chest
3. CHead down with the legs raised above the heart
4. DFlat on the back with the head turned well over to one side