Lembaran kerja Pemberian keutamaan & delegasi dengan jawapan

After caring for a patient with Clostridioides difficile diarrhea, how should the nurse clean their hands?

1. AWash with soap and water
2. BNo hand hygiene is needed if gloves were worn
3. CWipe hands on a clean towel
4. DUse alcohol hand rub only

A patient has a Glasgow Coma Scale score of 8. What is the main concern?

1. AThe patient only has a mild headache
2. BThe patient can safely eat and drink without help
3. CThe patient may not be able to protect the airway
4. DThe patient is fully alert and oriented

To which patients do standard precautions apply?

1. AOnly patients with an open wound
2. BOnly patients in intensive care
3. CAll patients, whether or not an infection is known
4. DOnly patients with a confirmed infection on a lab test

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

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

Seorang dewasa yang stabil dengan tanda vital normal mempunyai luka pada tangan yang memerlukan jahitan dan tiada yang lain. ESI tahap manakah yang sesuai?

1. ATahap 5
2. BTahap 2
3. CTahap 4
4. DTahap 3

On the first day after abdominal surgery, a patient has a temperature of 37.9 °C and reduced breath sounds at the lung bases. Which nursing action is most helpful?

1. AGive a cough suppressant so that the incision is not strained
2. BKeep the patient lying flat in bed to rest the incision fully
3. CRestrict oral fluids so that the lungs do not fill up with extra fluid
4. DEncourage deep breathing, coughing and use of the incentive spirometer

A patient with SIADH has a serum sodium of 120 mEq/L and is newly confused. Which nursing action has priority?

1. AEncouraging the patient to drink plenty of water
2. BHelping the patient to walk in the corridor alone
3. CSeizure precautions and close neurological checks
4. DTeaching the patient about a low-sodium diet at home

Discaj yang dirancang bagi pesakit manakah yang patut dipersoalkan oleh jururawat?

1. APesakit dua hari selepas pembedahan dengan kadar denyutan jantung baharu 112/min dan suhu 38.4 °C
2. BPesakit selepas pembaikan hernia yang sedang membuang air kecil dan makan
3. CPesakit pneumonia yang tidak demam selama 48 jam dengan antibiotik oral
4. DPesakit dengan simen yang stabil yang berjalan dengan selamat menggunakan tongkat ketiak