Lembar kerja Prioritas & delegasi dengan jawaban

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

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

What is a “near miss” in patient safety?

1. AA planned treatment that did not work
2. BA complaint from a visitor
3. CAn error that reached the patient and caused serious harm
4. DAn error that was caught before it reached the patient

Which hemoglobin result is low for an adult woman?

1. A14,0 g/dL (140 g/L)
2. B7,8 g/dL (78 g/L)
3. C13,2 g/dL (132 g/L)
4. D12,6 g/dL (126 g/L)

A patient reports pain of 8/10. Before giving the prescribed as-needed analgesic, what does the nurse do first?

1. ATell the patient to wait until the next scheduled dose is due in two hours
2. BGive the strongest analgesic on the chart straight away
3. CAsk the nursing assistant to reposition the patient
4. DAssess the location, character and onset of the pain and the vital signs

A nursing assistant tells the RN that a patient’s IV pump is alarming. What is the best response?

1. A“Turn the pump off and on again until it stops.”
2. B“I will come and check the pump and the IV site now.”
3. C“Increase the rate a little so the alarm clears.”
4. D“Silence the alarm and I will check it at the end of the shift.”

Five days after starting heparin, a patient’s platelet count has fallen by more than half. What should the nurse suspect?

1. AAn expected effect that needs no action
2. BIron deficiency anemia
3. CHeparin-induced thrombocytopenia
4. DVitamin K deficiency

An older patient with heart failure is receiving a second unit of blood. She becomes breathless, with crackles in both lungs and a rising blood pressure. What is most likely happening?

1. ATransfusion-associated circulatory overload
2. BAn expected effect of the first unit
3. CA mild allergic reaction with hives
4. DHypoglycemia caused by the stored blood product

On an addiction unit, which patient should the nurse assess first?

1. ADrowsy with pinpoint pupils and a respiratory rate of 7/min
2. BYawning, with a runny nose and dilated pupils
3. CAnxious, with goose bumps, stomach cramps and loose stools
4. DAsking for an extra blanket and a hot drink