Lembaran kerja Pemberian keutamaan & delegasi dengan jawapan

A patient’s platelet count is 18,000/mm³ (18 × 10⁹/L). Which risk is the nursing priority?

1. ABleeding
2. BFluid overload
3. CBlood clots
4. DInfection

Which task should the registered nurse not delegate to a nursing assistant?

1. AGiving a bed bath to a stable patient
2. BMaking an occupied bed
3. CWalking a stable patient up and down the corridor after lunch
4. DEvaluating whether the patient understood discharge teaching

Which triage method is designed for children in mass-casualty incidents?

1. AThe Braden Scale
2. BJumpSTART
3. CThe APGAR score
4. DThe Glasgow Coma Scale

Which medication order should the nurse question?

1. AOral potassium chloride with food
2. BPotassium chloride by IV push
3. CPotassium chloride oral solution diluted in juice
4. DPotassium chloride diluted in an IV bag via a pump

Menggunakan Emergency Severity Index, pesakit manakah yang menerima tahap ketajaman tertinggi?

1. APesakit dengan sakit tekak selama tiga hari dan tanda vital normal
2. BPesakit dengan sakit dada dan tanda vital normal
3. CPesakit dengan kemungkinan patah buku lali
4. DPesakit yang tidak responsif dengan nafas tercungap-cungap dan tidak teratur

A nurse cannot read part of a medication order. What should the nurse do?

1. AGive the usual dose of the drug the nurse thinks was meant
2. BContact the prescriber to clarify the order before giving the drug
3. CAsk another nurse to guess what the order most likely says, then give it
4. DSkip the drug and not tell anyone until the next ward round

A patient is deteriorating quickly. The nurse has called the provider twice, but the provider has not come. What is the best action?

1. ADocument the concern and continue routine care
2. BAsk the patient’s family to call the provider
3. CActivate the rapid response team
4. DWait another hour and call the provider again

Using ESI, a stable adult with abdominal pain will need blood tests and a CT scan, but has a heart rate of 130/min. Which statement is correct?

1. AVital signs never change the ESI level
2. BThe patient is level 4 because the blood tests and the scan count as one resource
3. CThe patient is level 5 because the pain is not severe
4. DThe nurse should consider level 2 because of the danger-zone vital sign