Lembar kerja Prioritas & delegasi dengan jawaban

Seorang asisten keperawatan melaporkan empat temuan. Mana yang harus diperiksa perawat lebih dulu?

1. APasien yang meminta selimut tambahan
2. BPasien yang ingin menelepon kerabat
3. CPasien yang nampan sarapannya tidak habis
4. DPasien yang tiba-tiba tidak dapat menggerakkan lengan kanannya

Which maneuver opens the airway of an unresponsive adult with no suspected spinal injury?

1. AJaw thrust without head tilt
2. BHead-tilt, chin-lift
3. CRaising the legs above the heart
4. DTurning the head sharply to one side

How many levels does the Emergency Severity Index have?

1. AFour
2. BSix
3. CThree
4. DFive

Which patient should the RN see first after receiving a report from the night nurse?

1. ADay 1 after bowel surgery, new chest pain and heart rate 110/min
2. BDay 3 after bowel surgery, wants a shower and hair wash before breakfast
3. CDay 4 after bowel surgery, waiting for discharge teaching
4. DDay 2 after bowel surgery, asking to start a soft diet

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

1. AWait for the provider to arrive before doing anything else
2. BRemove the tube and cover the site
3. CPlace the end of the tube in a bottle of sterile water
4. DClamp the tube for the rest of the shift

A patient taking warfarin has an INR of 5,2 and no signs of bleeding. What should the nurse do?

1. AGive a double dose to correct the result
2. BEncourage the patient to take aspirin for pain
3. CHold the warfarin dose and inform the provider
4. DGive the usual dose and recheck the INR next month

During JumpSTART triage, a child is not breathing after the airway is opened but has a palpable pulse. What is the next step?

1. ATag the child green and return to them after the others
2. BGive five rescue breaths; if breathing starts, tag the child red
3. CTag the child black at once and move on to the next victim
4. DStart full CPR on the child and stay with them until more help arrives

A nurse returns to the station to find four messages. Which one is answered first?

1. AThe pharmacy asks when the next delivery should be scheduled
2. BThe laboratory is calling with a critical potassium result of 2,6 mEq/L
3. CA colleague asks to swap shifts with them next week because of a family wedding
4. DA family member wants an update on their father’s progress