Lembar kerja Prioritas & delegasi dengan jawaban

What is the range of possible scores on the Glasgow Coma Scale?

1. A0 to 15
2. B3 to 15
3. C0 to 10
4. D1 to 20

Dalam soal prioritas, apa arti pasien "tidak stabil"?

1. APasien yang memiliki penyakit jangka panjang seperti diabetes
2. BPasien yang cemas dan menangis karena operasi besok
3. CPasien yang meminum lebih dari lima obat berbeda
4. DPasien yang kondisinya berubah atau sulit diprediksi

Using the PASS method for a fire extinguisher, what is the first step?

1. APull the pin
2. BSqueeze the handle
3. CAim at the base of the fire
4. DSweep from side to side

Which patient on an addiction unit should the nurse see first?

1. ALast drink two days ago; now shaking, sweating, heart rate 124/min and seeing insects
2. BLast drink this morning; asking when lunch will arrive
3. CIn recovery for a year; came to the clinic today for a routine check and a repeat prescription
4. DLast drink one week ago; asking about support groups

A patient has a serum potassium of 6,8 mEq/L. Which action comes first?

1. APlace the patient on a cardiac monitor
2. BEncourage foods high in potassium
3. CRecheck the level next week
4. DGive the patient’s scheduled potassium supplement

A patient with diabetes is unresponsive and has a blood glucose of 40 mg/dL (2,2 mmol/L). What should the nurse do first?

1. AGive the scheduled dose of insulin
2. BWait 15 minutes and recheck the glucose
3. CPour orange juice into the patient’s mouth
4. DGive IV dextrose or glucagon as prescribed

A patient with known abdominal aortic aneurysm suddenly has severe back pain, a pulsing mass in the abdomen and a falling blood pressure. What should the nurse do?

1. AEncourage the patient to walk to ease the back pain
2. BGive an oral analgesic and reassess the patient in about one hour
3. CCall for emergency help at once and prepare for urgent surgery
4. DPalpate the mass firmly to check its size and spread

Two days after starting haloperidol, a patient suddenly develops painful neck twisting and the eyes roll upwards. What should the nurse anticipate?

1. ANo action, because the spasm is a sign of improvement
2. BPhysical restraint until the spasm passes
3. CA higher dose of haloperidol to calm the patient and stop the movements quickly
4. DAn anticholinergic drug, such as benztropine or procyclidine, as prescribed