Lembar kerja Prioritas & delegasi dengan jawaban

What is a “critical value” in laboratory testing?

1. AA result that may be life-threatening and must be reported at once
2. BA result that is needed only for research
3. CA result that is slightly outside the normal range and can wait for the ward round
4. DA result that the patient has asked to see

A patient’s platelet count is 18,000/mm³ (18 × 10⁹/L). Which risk is the nursing priority?

1. AInfection
2. BBleeding
3. CBlood clots
4. DFluid overload

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

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

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

A patient with schizophrenia says voices are telling him to hurt his roommate. What is the priority?

1. ATell him the voices are not real and leave him alone
2. BAsk the roommate to stay in the room with him and help calm him down
3. CIgnore the comment, because voices are part of his illness
4. DKeep everyone safe and tell the team, as the risk of harm is high

An older patient becomes confused over a few hours, with attention that comes and goes. What does this suggest?

1. AA personality change that is permanent and expected
2. BLong-standing dementia that is expected
3. CDelirium, which needs the cause found quickly
4. DNormal aging that needs no action

A patient admitted with suspected appendicitis says the pain suddenly got better, but now the abdomen is rigid and the heart rate is rising. What does this suggest?

1. AThe appendicitis is getting better without surgery
2. BThe pain has moved to a different, harmless place
3. CThe patient’s analgesic has finally started to work
4. DThe appendix may have ruptured, causing peritonitis

A nurse teaches a patient to inject enoxaparin at home. Which statement shows a need for further teaching?

1. A“I will tell my doctor if I notice unusual bruising or bleeding.”
2. B“I will rub the area after the injection to help it absorb.”
3. C“I will change the injection site each time.”
4. D“I will inject into the fat of my abdomen, away from the navel.”