Lembaran kerja Pemberian keutamaan & delegasi dengan jawapan

Dalam rangka kerja ABC untuk menetapkan keutamaan kejururawatan, keperluan manakah yang ditangani dahulu?

1. APeredaran (Circulation)
2. BSaluran udara (Airway)
3. CKesakitan
4. DPernafasan (Breathing)

Which patient need belongs to the love and belonging level of Maslow’s hierarchy?

1. ANeeding the call light within reach
2. BNeeding pain relief after surgery
3. CWanting praise for progress in rehabilitation
4. DWanting family members to visit

Does asking a patient directly about suicidal thoughts increase their risk?

1. AOnly when the question is asked in writing
2. BYes; asking about it may give the patient the idea
3. COnly if the patient is over 65 years old
4. DNo; asking directly is safe and helps assess the risk

Which action helps prevent a catheter-associated urinary tract infection?

1. AKeeping the drainage bag below the level of the bladder
2. BDisconnecting the bag every shift to empty it
3. CRaising the drainage bag above the bladder when walking
4. DLeaving the catheter in place longer than needed

Which finding is an early sign of compartment syndrome in a patient with a lower leg fracture?

1. AMild bruising around the fracture site on the second day
2. BA strong pedal pulse with warm, pink toes and pain that settles with analgesia
3. CPain out of proportion to the injury that worsens when the toes are stretched
4. DItching under the cast during the first week after it was applied

A patient with type 1 diabetes has vomited since morning and cannot eat. Which action is most important?

1. AStop all insulin until the patient is able to eat normally again
2. BWait until tomorrow to see if the vomiting settles
3. CCheck the blood glucose and ketones and contact the provider
4. DEncourage a large meal to settle the stomach

After a head injury, a patient has clear fluid dripping from the nose. Which action should the nurse avoid?

1. AInserting a tube or suction catheter through the nose
2. BPlacing a loose gauze under the nose
3. CInforming the provider about the drainage
4. DChecking the fluid for glucose or a halo sign on gauze

Laporan pembantu jururawat manakah yang patut ditindaki dahulu oleh jururawat?

1. APesakit yang berehat di katil meminta pan katil
2. BPesakit pneumonia telah batuk kahak kuning
3. CPesakit diabetes berkata kakinya sering terasa kebas-kebas, seperti kebiasaannya
4. DSelepas pelakuran tulang belakang lumbar pagi ini, tidak dapat merasa atau menggerakkan kaki