Lembar kerja Prioritas & delegasi dengan jawaban

What does the Morse Fall Scale measure?

1. AA patient’s nutrition status
2. BA patient’s pain level
3. CA patient’s risk of falling
4. DA patient’s skin integrity

Which symptoms suggest high blood glucose (hyperglycemia)?

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

Which statement belongs in the Background part of an SBAR report?

1. A“I think he may be developing sepsis.”
2. B“He was admitted three days ago with pneumonia and also has COPD.”
3. C“I am calling about Mr Khan because his blood pressure has dropped.”
4. D“I would like you to see him within the next 15 minutes.”

A nurse teaches a patient about sublingual nitroglycerin tablets. Which statement shows a need for further teaching?

1. A“I may get a headache after taking a tablet.”
2. B“I will swallow the tablet with a glass of water.”
3. C“I will keep the tablets in their original dark container.”
4. D“I will sit down before I take a tablet.”

Which SBAR recommendation is the clearest?

1. A“I would like you to see him within 15 minutes and consider a fluid bolus.”
2. B“He seems a bit off tonight, so maybe you could come up and do something about it.”
3. C“I just wanted to let you know about him.”
4. D“I will keep watching him and call again tomorrow.”

A patient reports pain of 8/10. Before giving the prescribed as-needed analgesic, what does the nurse do first?

1. AAsk the nursing assistant to reposition the patient
2. BGive the strongest analgesic on the chart straight away
3. CAssess the location, character and onset of the pain and the vital signs
4. DTell the patient to wait until the next scheduled dose is due in two hours

A patient is admitted with suspected meningococcal meningitis. Which precautions are needed until treatment has been given for long enough?

1. AContact precautions only
2. BDroplet precautions
3. CAirborne precautions
4. DStandard precautions only

An infant with pyloric stenosis has repeated projectile vomiting. Which acid-base imbalance is most likely?

1. AMetabolic acidosis
2. BRespiratory acidosis
3. CMetabolic alkalosis
4. DRespiratory alkalosis