Lembaran kerja Pemberian keutamaan & delegasi dengan jawapan

Dalam penetapan keutamaan, dapatan yang "dijangka" ialah dapatan yang:

1. ATelah diramal oleh pesakit atau keluarga
2. BSentiasa berada dalam julat rujukan dewasa yang normal
3. CSesuai dengan keadaan atau rawatan pesakit yang diketahui
4. DSentiasa memerlukan panggilan segera kepada pasukan tindak balas pantas

A patient’s respiratory rate is 30/min at rest. How should the nurse classify this finding in an adult?

1. AAbnormally fast and needing assessment
2. BNormal after a meal
3. CWithin the normal adult range
4. DSlow, and expected while the patient is asleep

Which body temperature is a fever in an adult?

1. A37.1 °C
2. B36.4 °C
3. C36.8 °C
4. D38.5 °C

A patient with asthma uses a peak flow meter. A reading below 50% of personal best is in the red zone. Which statement shows correct understanding?

1. A“I will wait until tomorrow morning to see if the reading gets better on its own.”
2. B“I will use my reliever inhaler and get emergency help straight away.”
3. C“I will go for a short run to open up my lungs.”
4. D“I will stop all my inhalers until the reading is back up.”

A patient’s chest tube becomes disconnected from the drainage system. What should the nurse do first?

1. ARemove the tube and cover the site
2. BWait for the provider to arrive before doing anything else
3. CPlace the end of the tube in a bottle of sterile water
4. DClamp the tube for the rest of the shift

Which action by a nursing assistant needs the nurse to step in?

1. APutting the call light within the patient’s reach
2. BTaking an oral temperature just after the patient drank cold water
3. CCleaning hands before entering the room
4. DLowering the bed to its lowest position and locking the wheels after care

A patient was knocked out briefly in a fall, then woke and talked normally. Two hours later the patient becomes drowsy and one pupil is larger. What is the most likely cause?

1. ANormal tiredness after a fall
2. BAn epidural hematoma
3. CA mild concussion that is settling
4. DLow blood sugar from missing a meal

Seorang jururawat menyelia pembantu jururawat yang baharu. Bilakah jururawat patut memeriksa kerja pembantu dengan paling rapi?

1. ATidak pernah, kerana pembantu memegang sijil untuk peranan itu
2. BHanya pada akhir syif, apabila dokumentasi disemak
3. CHanya apabila pembantu meminta bantuan dengan tugas yang dirasainya sukar
4. DApabila pembantu baharu kepada tugas itu atau pesakit kurang stabil