Lembar kerja Prioritas & delegasi dengan jawaban

In the ABC framework, which finding is mainly a breathing problem?

1. AShallow breaths with an SpO₂ of 85% on room air
2. BHeart rate 150/min with a low blood pressure and cold skin
3. CStridor caused by a swollen throat
4. DA blood glucose of 60 mg/dL (3,3 mmol/L)

Before giving a medication, how many patient identifiers should the nurse check?

1. AOne, the bed number
2. BAt least two, such as name and date of birth
3. COne, the room number
4. DNone, if the nurse already knows the patient well

Which patient need belongs to the love and belonging level of Maslow’s hierarchy?

1. ANeeding pain relief after surgery
2. BNeeding the call light within reach
3. CWanting family members to visit
4. DWanting praise for progress in rehabilitation

Several patients on a gastroenterology unit need care. Which patient should the nurse see first?

1. ATwo hours after a colonoscopy: rigid abdomen and severe new pain
2. BLong-standing back pain, asking for the usual analgesic
3. CCrohn disease, waiting to be taken down for a scheduled CT scan
4. DUlcerative colitis, asking about diet changes for home

A patient taking clozapine reports a sore throat and fever. What is the priority action?

1. AAdvise the patient to gargle with warm salt water and rest in bed
2. BIncrease the dose because the symptoms suggest a relapse
3. COffer throat lozenges and continue the usual dose
4. DHold the dose and report so the white cell count can be checked

Pasien mana yang dapat dengan aman ditemui perawat terakhir?

1. APasien PPOK dengan oksigen 1 L/menit, SpO₂ 90% (target 88–92%), berbicara dalam kalimat penuh
2. BPasien dengan sakit kepala hebat mendadak
3. CPasien dengan ronki baru dan dahak berbuih merah muda
4. DPasien dua jam setelah operasi dengan denyut jantung naik dari 88 menjadi 118/menit

Which patient needs airborne precautions rather than droplet precautions?

1. AA teenager with mumps
2. BA child with pertussis (whooping cough)
3. CAn adult with influenza
4. DA child with chickenpox (varicella)

Which patient finding after a total knee replacement needs the nurse’s action first?

1. APain of 4/10 when the physiotherapist bends the knee during the morning session
2. BSudden calf pain and swelling in the operated leg, with new breathlessness
3. CAsks for an ice pack to help with swelling around the knee
4. DA small amount of dried blood on the dressing