Lembar kerja Prioritas & delegasi dengan jawaban

Which drug reverses the anticoagulant effect of heparin?

1. AProtamine sulfate
2. BVitamin K
3. CNaloxone
4. DAtropine

Which capillary refill time is prolonged in an adult?

1. ALess than 1 second
2. B4 seconds
3. C2 seconds
4. D1 second

Which symptoms suggest high blood glucose (hyperglycemia)?

1. AIncreased thirst and passing more urine
2. BConfusion that improves quickly with juice
3. CSweating, shaking and a fast pulse
4. DSudden hunger with cold, clammy skin

A patient coughs hard after abdominal surgery, and loops of bowel appear through the opened wound. What does the nurse do first?

1. AHelp the patient walk to the toilet to relieve abdominal pressure
2. BCover the wound with sterile dressings moistened with saline
3. CLeave the wound uncovered so the surgeon can see it on arrival
4. DPush the bowel gently back into the abdomen with a gloved hand

A patient receiving chemotherapy has a temperature of 38,3 °C and a very low neutrophil count. What should the nurse do?

1. AGive a cool shower and offer extra fluids, then wait and see what happens
2. BDocument the reading and mention it at the next handover
3. CReport it at once, because cultures and antibiotics are needed quickly
4. DRecheck the temperature in four hours before telling anyone

Which postoperative patient should the nurse see first?

1. ADressing soaked with bright red blood and a heart rate rising to 118/min
2. BAsking when the urinary catheter will be removed
3. CWants help with washing her hair before her visitors arrive this afternoon
4. DPain of 4/10 one hour after an oral analgesic

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

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

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