Lembar kerja Prioritas & delegasi dengan jawaban

Which capillary refill time is prolonged in an adult?

1. A4 seconds
2. B2 seconds
3. CLess than 1 second
4. D1 second

Manakah yang termasuk lima benar (rights) dalam pendelegasian?

1. AWaktu dan frekuensi yang benar
2. BRute dan lokasi penyuntikan yang benar
3. CPengawasan dan evaluasi yang benar
4. DDosis dan kekuatan yang benar

A patient’s respiratory rate is 30/min at rest. How should the nurse classify this finding in an adult?

1. ANormal after a meal
2. BWithin the normal adult range
3. CSlow, and expected while the patient is asleep
4. DAbnormally fast and needing assessment

A drowsy patient who has just returned from surgery starts to vomit. What should the nurse do first?

1. AGive an oral anti-sickness tablet
2. BTurn the patient onto their side
3. CRaise the legs above the heart
4. DGive a drink of water

A patient’s chest tube becomes disconnected from the drainage system. What should the nurse do first?

1. ARemove the tube and cover the site
2. BPlace the end of the tube in a bottle of sterile water
3. CClamp the tube for the rest of the shift
4. DWait for the provider to arrive before doing anything else

A nurse teaches a patient with COPD pursed-lip breathing. Which statement shows a need for further teaching?

1. A“I will breathe in through my mouth and out quickly through my nose.”
2. B“I will make my breath out about twice as long as my breath in.”
3. C“I will breathe out slowly through pursed lips.”
4. D“I will breathe in slowly through my nose.”

A patient at 32 weeks of pregnancy feels dizzy and faint while lying flat on her back. What should the nurse do first?

1. AGive her a sugary drink and keep her flat
2. BRaise her legs while she stays on her back
3. CSit her upright with her head between her knees
4. DTurn her onto her left side

Using ESI, a stable adult with abdominal pain will need blood tests and a CT scan, but has a heart rate of 130/min. Which statement is correct?

1. AThe patient is level 5 because the pain is not severe
2. BVital signs never change the ESI level
3. CThe nurse should consider level 2 because of the danger-zone vital sign
4. DThe patient is level 4 because the blood tests and the scan count as one resource