Lembaran kerja Pemberian keutamaan & delegasi dengan jawapan

What does the Morse Fall Scale measure?

1. AA patient’s risk of falling
2. BA patient’s nutrition status
3. CA patient’s pain level
4. DA patient’s skin integrity

Seorang pesakit mengalami trombosis vena dalam yang baharu dan juga berkata dia berasa sunyi di wad. Menggunakan hierarki Maslow, keperluan manakah yang didahulukan?

1. AKeperluan harga diri dan penghormatan
2. BKeperluan fisiologi yang berkaitan dengan trombosis
3. CKeperluan pengaktualan diri
4. DKeperluan kasih sayang dan kepunyaan semasa tinggal di hospital

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

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

A nursing assistant offers to suction a patient’s new tracheostomy. Which response from the RN is best?

1. A“Suctioning a new tracheostomy is my task; I will do it myself.”
2. B“Leave the suctioning until the next shift arrives.”
3. C“Ask the patient’s family to do the suctioning today.”
4. D“Thank you, please suction him as needed and tell me how it went.”

A patient on a nasal cannula at 6 L/min still has a low SpO₂. What should the nurse do?

1. ATurn the nasal cannula up to 15 L/min
2. BRecheck the SpO₂ at the next routine set of observations in four hours
3. CRemove the oxygen to see if the SpO₂ changes
4. DReport it, because a different oxygen device is likely to be needed

A nurse teaches a patient about sublingual nitroglycerin tablets. Which statement shows a need for further teaching?

1. A“I will keep the tablets in their original dark container.”
2. B“I will sit down before I take a tablet.”
3. C“I may get a headache after taking a tablet.”
4. D“I will swallow the tablet with a glass of water.”

During an infusion of a thrombolytic drug for stroke, the patient develops a severe headache and starts vomiting. What should the nurse do first?

1. AStop the infusion and inform the provider at once
2. BContinue the infusion, because headache is expected
3. CSlow the infusion and give an antiemetic as prescribed
4. DGive a dose of aspirin for the headache

Which nursing approach may raise intracranial pressure in a patient with a head injury?

1. ASpacing out care with rest periods in between activities
2. BDoing suctioning, turning and bathing all at the same time
3. CKeeping the head in line with the body
4. DKeeping the room calm and quiet