Lembar kerja Prioritas & delegasi dengan jawaban

Which task is appropriate to delegate to a nursing assistant?

1. AAssessing a pressure injury on the sacrum
2. BFeeding a patient with newly diagnosed dysphagia after a stroke
3. CFeeding a stable patient who has no swallowing problems
4. DGiving a stable patient their oral medications

Which medication reverses opioid-induced respiratory depression?

1. AVitamin K
2. BFlumazenil
3. CProtamine sulfate
4. DNaloxone

Manakah yang merupakan kebutuhan fisiologis dalam hierarki Maslow?

1. AMerasa menjadi bagian dari keluarga
2. BMerasa aman di rumah
3. CDihormati oleh orang lain
4. DEliminasi urine dan feses

An older patient with dementia is restless at night and keeps trying to get out of bed. Which measure should the nurse try first?

1. AGive a sedative from the as-needed list without first assessing the patient
2. BRaise all four bed rails so the patient cannot climb out
3. CCheck for pain, thirst or a full bladder, and offer toileting
4. DApply wrist restraints for the rest of the night

Before accessing a central venous catheter, what should the nurse do to prevent infection?

1. ABlow on the hub to remove any dust before connecting the syringe or line
2. BTouch the hub to check it is clean
3. CScrub the hub with an antiseptic such as chlorhexidine and let it dry
4. DRinse the hub with tap water and dry it

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

1. A“I will not use oil-based creams on my face.”
2. B“My husband can smoke in my room if the window is open.”
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.”

A patient is bleeding internally after a fall. Which finding is usually an early sign of hypovolemic shock?

1. ALoss of consciousness with gasping breaths
2. BA very low blood pressure with fixed, dilated pupils
3. CRestlessness and a rising heart rate while the blood pressure is still normal
4. DA slow heart rate with warm, dry, flushed skin and a normal blood pressure throughout

A patient has a chest drain for a pneumothorax. The nurse sees constant bubbling in the water-seal chamber. What does this most likely mean?

1. AThe lung has fully re-expanded, so the drain is ready to come out
2. BThe suction is set too low and needs to be turned up
3. CThe drain is working normally and no action is needed
4. DAn air leak in the patient or the system that needs checking