Lembar kerja Prioritas & delegasi dengan jawaban

Tugas mana yang harus dipegang sendiri oleh perawat terdaftar dan tidak didelegasikan kepada tenaga asisten tanpa lisensi?

1. AMengukur dan mencatat asupan dan keluaran cairan
2. BMemandikan pasien yang stabil
3. CPengkajian awal pasien yang baru masuk
4. DMembantu pasien yang stabil berjalan ke kamar mandi dan kembali

Which pain scale is designed for infants and young children who cannot describe their pain?

1. AThe Braden Scale
2. BThe Glasgow Coma Scale
3. CThe Morse Fall Scale
4. DThe FLACC scale

Masalah pasien mana yang umumnya memiliki prioritas tertinggi?

1. AObstruksi jalan napas
2. BNyeri akut
3. CKecemasan
4. DDefisit pengetahuan tentang obat

After a hip replacement, a patient has sudden severe hip pain, and the operated leg looks shorter and turned. What should the nurse suspect?

1. AA pressure injury on the heel
2. BNormal pain after surgery
3. CDislocation of the new hip
4. DA urinary tract infection

A nurse teaches a patient who has started warfarin. Which statement shows a need for further teaching?

1. A“I will use a soft toothbrush.”
2. B“I will tell my dentist and pharmacist that I take warfarin.”
3. C“I will keep my INR blood test appointments.”
4. D“If I miss a dose, I will take two the next day.”

A drowsy patient has an arterial blood gas with pH 7,30, PaCO₂ 58 mmHg (7,7 kPa) and HCO₃⁻ 25 mEq/L (mmol/L). Which problem is the priority?

1. APoor ventilation causing carbon dioxide to build up
2. BToo much bicarbonate from antacids
3. CLoss of bicarbonate from the bowel through severe diarrhea
4. DHyperventilation caused by anxiety

Setelah serah terima, pasien mana yang harus dikaji perawat lebih dulu?

1. A1 jam setelah kateterisasi jantung melalui femoralis: nyeri punggung baru, nadi 118/menit, TD 92/58 mmHg
2. BDiabetes tipe 2: glukosa 210 mg/dL (11,7 mmol/L) sebelum makan siang, tanpa gejala
3. CHari ke-2 setelah operasi kandung empedu: nyeri 6/10, analgesik berikutnya dijadwalkan 30 menit lagi
4. DPPOK dengan oksigen 2 L/menit: SpO₂ 90%, frekuensi napas 22/menit, pada kondisi dasarnya

A patient with diabetes takes propranolol. Which sign of hypoglycemia is most likely to still appear?

1. ATachycardia
2. BPalpitations
3. CSweating
4. DTremor