Lembar kerja Prioritas & delegasi dengan jawaban

In the Emergency Severity Index (ESI), which patient fits level 2?

1. AA stable patient who needs one resource
2. BA stable patient who needs no resources
3. CA high-risk situation, new confusion, or severe pain or distress
4. DA patient who needs an immediate life-saving intervention to survive

Which term describes a patient who is unable to understand and decide about their own care?

1. ALacking decision-making capacity
2. BExercising autonomy
3. CProviding valid informed consent
4. DFully competent

Using the rule of nines, what percentage of body surface does one whole arm represent in an adult?

1. A1%
2. B9%
3. C18%
4. D36%

An arterial blood gas shows pH 7,28, PaCO₂ 40 mmHg (5,3 kPa) and HCO₃⁻ 16 mEq/L (mmol/L). How should the nurse interpret it?

1. ARespiratory acidosis
2. BRespiratory alkalosis
3. CMetabolic alkalosis
4. DMetabolic acidosis

A patient on hemodialysis has an arteriovenous fistula in the left arm. Which instruction should the nurse give the nursing assistant?

1. ADo not measure blood pressure on the left arm
2. BHelp the patient carry shopping bags on the left arm
3. CMeasure blood pressure on the left arm only, every 4 hours
4. DKeep the left arm wrapped tightly in a bandage at night

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

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

At 08:00 a nurse has four tasks. Which order is best?

1. AGive routine medications, check the patient with a falling SpO₂, update care plans, give insulin with breakfast
2. BCheck the patient with a falling SpO₂, give insulin with breakfast, give routine medications, update care plans
3. CUpdate care plans, give insulin with breakfast, give routine medications, check the patient with a falling SpO₂
4. DGive insulin with breakfast, update care plans, check the patient with a falling SpO₂, give routine medications

A patient has a potassium of 7,0 mEq/L with peaked T waves. Several drugs are prescribed. Which one is usually given first to protect the heart?

1. AIV calcium gluconate
2. BIV furosemide
3. COral potassium binder
4. DOral sodium bicarbonate