Lembaran kerja Kejururawatan klinikal dengan jawapan

Kawasan merah yang tidak memucat pada kulit utuh di atas sakrum dikelaskan sebagai kategori ulser tekanan yang mana?

1. AKategori 4
2. BKategori 3
3. CKategori 1
4. DKategori 2

Peraturan sembilan (rule of nines) menganggarkan:

1. ABilangan nafas seminit
2. BCecair yang hilang akibat muntah
3. CPeratusan luas permukaan badan yang terjejas oleh luka bakar
4. DKedalaman luka bakar, diukur dalam milimeter kulit

After a stroke, a patient has "aphasia". What does this mean?

1. AWeakness of one side of the body
2. BLoss of vision in one eye
3. CDifficulty understanding or producing language
4. DDifficulty swallowing food, drink and saliva

After removing a peripheral IV cannula, what should the nurse check?

1. AThat the site is left uncovered and bleeding freely
2. BThat the cannula is intact, and apply pressure until bleeding stops
3. CThat the patient's blood glucose is normal before removal
4. DThat the cannula is put back in its sterile packet for the next patient

In UK guidance, neutropenic sepsis is commonly defined by a temperature above 38 °C or signs of sepsis with a neutrophil count at or below:

1. A150 × 10⁹/L
2. B5 × 10⁹/L
3. C15 × 10⁹/L
4. D0.5 × 10⁹/L

Which blood result often rises in an upper GI bleed because blood is digested in the gut?

1. AGlucose
2. BCalcium
3. CSodium
4. DUrea (blood urea nitrogen)

After a head injury, a patient has clear fluid leaking from the nose. What does this most likely suggest?

1. AA normal and harmless response to head trauma
2. BA base-of-skull fracture with a cerebrospinal fluid leak
3. CAcute sinusitis
4. DAllergic rhinitis triggered by the hospital environment

Pesakit pascaoperasi mempunyai kadar jantung 115/min, suhu 38.6 °C, kadar pernafasan 26/min dan tekanan darah 85/50 mmHg walaupun telah diberi bolus cecair. Apakah yang paling mungkin ditunjukkan oleh ini?

1. ADehidrasi ringan sahaja
2. BKebimbangan tentang pelepasan
3. CKejutan septik yang memerlukan semakan rawatan rapi segera
4. DTindak balas keradangan normal pada hari-hari pertama selepas pembedahan