Lembaran kerja Pemberian keutamaan & delegasi dengan jawapan

Dalam triaj korban beramai-ramai, apakah maksud tag merah biasanya?

1. ADitangguhkan: kecederaan serius, tetapi stabil buat masa ini
2. BSegera: mengancam nyawa tetapi boleh diselamatkan dengan penjagaan pantas
3. CDijangka maut: tidak mungkin terselamat walaupun dengan penjagaan, atau sudah meninggal dunia
4. DKecil: orang itu boleh berjalan dan boleh menunggu dengan selamat

Which statement about the nursing process is correct when setting priorities?

1. AEvaluation comes first, before any patient data have been collected
2. BImplementation comes first, so care starts quickly
3. CAssessment comes first, because the other steps depend on it
4. DPlanning comes first, before seeing the patient

Which finding is one of the quick SOFA (qSOFA) criteria for possible sepsis?

1. ABlood glucose above 100 mg/dL
2. BHeart rate below 60/min
3. CTemperature below 36.5 °C on one reading
4. DRespiratory rate of 22/min or more

A nurse needs to give report on a patient to a colleague. Which information is the most important to include?

1. AThe patient’s current condition, recent changes and pending tasks
2. BDetails of the nurse’s own break times that shift
3. CThe patient’s favorite television programs and hobbies
4. DPersonal opinions about the patient’s family members and their visiting habits

A patient receiving IV magnesium sulfate for pre-eclampsia has absent knee reflexes and a respiratory rate of 10/min. What does the nurse do first?

1. AStop the magnesium infusion and call for help
2. BIncrease the infusion to prevent a seizure
3. CTurn the patient onto her back and recheck later
4. DGive oral fluids to help clear the drug faster

During a blood transfusion, a patient develops chills, back pain and a fever. What is the nurse’s first action?

1. AGive an antipyretic and continue the transfusion
2. BFinish the unit quickly through a pressure bag so that the reaction does not last long
3. CStop the transfusion and keep the IV open with normal saline via new tubing
4. DSlow the transfusion and recheck in an hour

Seorang pesakit warga emas dengan pneumonia baru keliru. Tindakan manakah yang didahulukan?

1. ATanya keluarga sama ada ini normal bagi pesakit
2. BPasang kekangan pergelangan tangan untuk menghalang pesakit menarik IV
3. CBeri sedatif yang ditetapkan apabila diperlukan
4. DPeriksa ketepuan oksigen dan tanda vital lain

A child who had a tonsillectomy this morning is swallowing again and again while asleep. What should the nurse suspect?

1. AHunger after fasting for surgery
2. BNormal swallowing during sleep
3. CA sore throat from the breathing tube
4. DBleeding from the operation site