Lembar kerja Prioritas & delegasi dengan jawaban

Pada triase korban massal, apa arti label hitam?

1. AMeninggal, atau kecil kemungkinan bertahan hidup dengan sumber daya yang tersedia
2. BPrioritas penanganan tertinggi dari semua korban
3. CCedera ringan yang dapat menunggu berjam-jam
4. DTerkontaminasi, memerlukan dekontaminasi penuh sebelum perawatan apa pun diberikan

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

1. AAt least two, such as name and date of birth
2. BOne, the room number
3. CNone, if the nurse already knows the patient well
4. DOne, the bed number

Which serum potassium result should the nurse report to the provider promptly?

1. A4,2 mEq/L (4,2 mmol/L)
2. B3,8 mEq/L (3,8 mmol/L)
3. C4,9 mEq/L (4,9 mmol/L)
4. D6,4 mEq/L (6,4 mmol/L)

Which patient is most suitable for the nurse to assign to a nurse who has just finished orientation?

1. AA patient with sepsis whose blood pressure is falling
2. BA patient on a continuous heparin infusion with rising aPTT values
3. CA patient with a new tracheostomy who needs frequent suctioning
4. DA patient with stable cellulitis on scheduled IV antibiotics

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

A patient has taken prednisone (prednisolone in many countries) for several months. Which statement shows a need for further teaching?

1. A“I will tell my dentist and other doctors that I take a steroid.”
2. B“I will take the tablets with food.”
3. C“I will stop the tablets as soon as I feel better.”
4. D“I will report signs of infection early.”

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

Seorang pasien dengan cedera kepala dan patah tulang tungkai sedang dipantau. Temuan mana yang menjadi prioritas?

1. APasien meminta sesuatu untuk dimakan
2. BNyeri tungkai 6/10 meskipun sudah diberi dosis analgesik terakhir
3. CSkor Glasgow Coma Scale turun dari 15 menjadi 12
4. DLecet kecil di siku