Lembaran kerja Pemberian keutamaan & delegasi dengan jawapan

Which patient is unstable?

1. AA patient with a healing leg wound and normal vital signs this morning
2. BA patient with long-standing arthritis pain of 3/10
3. CA patient waiting for a planned hip X-ray
4. DA patient with a new irregular pulse who says they feel dizzy

In mass-casualty triage, what does a yellow tag usually mean?

1. AMinor: the walking wounded
2. BImmediate: life-threatening injuries that are survivable with quick care
3. CDeceased or not expected to survive
4. DDelayed: serious injuries, but care can safely wait a little

In Maslow’s hierarchy of needs, which level sits at the top?

1. ALove and belonging
2. BSelf-actualization
3. CSafety and security
4. DEsteem

A patient with heart failure gained 2 kg (about 4 lb) since yesterday and is more breathless when lying down. What should the nurse do first?

1. ALay the patient flat to help them breathe more easily
2. BRecord the weight on the chart and recheck it at the next weekly weigh-in
3. CAssess the lungs, oxygen saturation and swelling, then inform the provider
4. DEncourage extra fluids to correct the weight change

Several patients on a gastroenterology unit need care. Which patient should the nurse see first?

1. ATwo hours after a colonoscopy: rigid abdomen and severe new pain
2. BLong-standing back pain, asking for the usual analgesic
3. CUlcerative colitis, asking about diet changes for home
4. DCrohn disease, waiting to be taken down for a scheduled CT scan

When making patient assignments, what should the charge nurse consider first?

1. AGiving the newest staff the most complex patients
2. BLetting staff choose the patients they prefer
3. CGiving each nurse patients in rooms next to each other
4. DMatching each patient’s needs to staff competence

A patient admitted with a stroke this morning asks for a glass of water. What should the nurse do first?

1. AGive thickened fluids without checking the swallow
2. BGive the water through a straw so it goes down slowly
3. CAsk the family to help the patient drink while sitting upright in a chair at the bedside
4. DCheck that a swallow screen has been done before giving anything by mouth

Which patient with cirrhosis should the nurse see first?

1. AVomiting bright red blood, heart rate 120/min
2. BLarge ascites that is unchanged from yesterday
3. CWants to talk about stopping drinking alcohol for good
4. DLong-standing jaundice and itchy skin, asking for cream