Lembar kerja Prioritas & delegasi dengan jawaban

What does the Morse Fall Scale measure?

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

What is the normal baseline fetal heart rate?

1. A160–220/min
2. B110–160/min
3. C40–60/min
4. D60–100/min

Which platelet count is within the normal adult range?

1. A40,000/mm³ (40 × 10⁹/L)
2. B700,000/mm³ (700 × 10⁹/L)
3. C250,000/mm³ (250 × 10⁹/L)
4. D90,000/mm³ (90 × 10⁹/L)

A nurse teaches a patient with heart failure. Which statement shows a need for further teaching?

1. A“I will call if my weight goes up quickly over a day or two.”
2. B“I add extra salt to my food so it tastes better.”
3. C“I will weigh myself every morning after I use the toilet.”
4. D“I will take my water tablet in the morning.”

A patient with a head injury is being monitored. Which set of findings suggests rising intracranial pressure?

1. AFalling blood pressure, a fast pulse and warm, flushed dry skin
2. BLow temperature, fast breathing and a strong appetite
3. CRising systolic pressure, slow pulse and irregular breathing
4. DNormal blood pressure, normal pulse and clear speech

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

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

A 2-month-old infant has a spiral fracture of the femur. The parents say the baby rolled off the sofa. What should the nurse recognize?

1. AA spiral fracture in an infant is always caused by birth trauma
2. BThe injury does not fit the infant’s development, so possible abuse must be reported
3. CInfants of this age often roll off furniture and break bones in this way
4. DNo further action is needed once the fracture is treated

Temuan pasien mana yang paling mendesak?

1. APasien setelah operasi lutut dengan memar kecil di lokasi suntikan
2. BPasien dengan warfarin dan INR 2,5 yang dijadwalkan menerima dosis sore yang biasa
3. CPasien dengan infus heparin yang mengalami kebingungan baru dan sakit kepala hebat
4. DPasien yang hasil hitung trombositnya masih menunggu