Lembar kerja Prioritas & delegasi dengan jawaban

Dalam kerangka ABC untuk menetapkan prioritas keperawatan, kebutuhan mana yang ditangani lebih dulu?

1. APernapasan (Breathing)
2. BNyeri
3. CSirkulasi (Circulation)
4. DJalan napas (Airway)

What is the normal baseline fetal heart rate?

1. A160–220/min
2. B60–100/min
3. C110–160/min
4. D40–60/min

What is status epilepticus?

1. AA faint caused by standing up too quickly
2. BA seizure lasting 5 minutes or more, or repeated seizures without recovery
3. CA single short seizure that stops on its own within a minute or two
4. DA seizure that happens only during sleep

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

During labor, the nurse sees the umbilical cord in the vagina after the membranes rupture. What is the first action?

1. ARelieve pressure on the cord by lifting the presenting part with a gloved hand
2. BAsk the patient to walk around the room to bring the baby lower and speed up labor
3. CPush the cord back into the uterus
4. DWait for the next contraction before acting

A patient is receiving a blood transfusion. Which task can the nurse delegate to a nursing assistant?

1. ADeciding whether to stop the transfusion if the patient has chills
2. BStarting the transfusion once the blood arrives
3. CMeasuring and reporting vital signs at the times set by the nurse
4. DAssessing the patient for signs of a transfusion reaction

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

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

Empat pasien tiba di instalasi gawat darurat bersamaan. Siapa yang harus dilihat lebih dulu?

1. ARemaja dengan luka sayat di lengan yang perdarahannya terkendali
2. BOrang dewasa dengan migrain dan tekanan darah 150/90 mmHg
3. CAnak 2 tahun yang air liurnya menetes, duduk condong ke depan, dan memiliki stridor
4. DOrang dewasa dengan pergelangan kaki berubah bentuk dan nadi normal di kaki