Lembar kerja Prioritas & delegasi dengan jawaban

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

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

Which resting heart rate in an adult is bradycardia?

1. A46/min
2. B88/min
3. C72/min
4. D64/min

When a nurse receives a critical lab result by phone, what does “read-back” mean?

1. AReading the result to the next shift at handover
2. BWaiting for the written report before doing anything
3. CReading the result aloud to the patient straight away
4. DRepeating the result back to the caller to confirm it

A child with fever and headache develops a purple rash that does not fade when pressed with a glass. What should the nurse do?

1. AApply a soothing cream to the rash
2. BGive acetaminophen (paracetamol) and reassess in four hours
3. CTreat it as an emergency and escalate at once
4. DAdvise the family to see their doctor next week

A patient coughs hard after abdominal surgery, and loops of bowel appear through the opened wound. What does the nurse do first?

1. AHelp the patient walk to the toilet to relieve abdominal pressure
2. BLeave the wound uncovered so the surgeon can see it on arrival
3. CPush the bowel gently back into the abdomen with a gloved hand
4. DCover the wound with sterile dressings moistened with saline

A patient on a continuous IV heparin infusion has new black, tarry stools and an aPTT well above the target range. What should the nurse do first?

1. AStop the heparin infusion and inform the provider
2. BCheck the pump rate and leave the infusion running
3. COffer an iron-rich meal to replace the lost blood
4. DGive a dose of vitamin K by mouth

Pada giliran jaga yang sibuk, empat tugas jatuh tempo. Mana yang harus dikerjakan perawat lebih dulu?

1. ADosis pertama antibiotik IV untuk pasien dengan dugaan sepsis
2. BMemberikan tablet vitamin harian rutin yang jatuh tempo pada saat yang sama
3. CMembantu pasien stabil mengisi kartu menu besok
4. DMemperbarui rencana asuhan keperawatan sebelum audit para manajer

Seorang perawat menganggap dosis yang diresepkan tidak aman. Penulis resep mengatakan agar tetap diberikan. Apa yang harus dilakukan perawat?

1. AMemberikan setengah dosis sebagai kompromi dan mendokumentasikan alasannya
2. BMelewatkan dosis diam-diam dan tidak mengatakan apa-apa untuk menghindari konflik
3. CMenahan dosis dan melakukan eskalasi melalui rantai komando
4. DMemberikan dosis tersebut, karena penulis resep kini bertanggung jawab atasnya