Nama : Rahmat Aji Wibowo

NIM : 01.2.16.005555

1. A 74-year-old woman entered with complaints of tightness, currently treatment day 3. The
results of the study found cough patients accompanied by phlegm, ronchi in all lung fields.
TTV: TD = 120/80 mmHg, N = 56x / min P = 26x / min and S = 36: C. ECG results:
bradycardia, pathological Q II, III, AVF, V5-V6. Thoracic results: right pleural effusion and
LVH.
What is the nursing diagnosis in the above case?
a. Decreased cardiac output
b. Activity tolerance
c. Damage to gas exchange
d. Cleaning the airway is not effective
e.Fatigue

2. 67-year-old man came to the hospital emergency room with complaints of pain due to
voiding during the last 1 day, the results of the assessment of the pain level of the patient
were obtained at scale 4 (1-5), the face looked grimaced and looked in pain. If triage is
included in what category is the client?
a. Red (emergency department)
b. Yellow (non-emergency)
c. Yellow (emergency is not serious)
d.Green (no emergency not emergency)
e.Black (died)

3. A 75-year-old man suffering from CVA was admitted to the hospital. The client has a left
side weakness and no gag reflexes. He wet the bed and his stools were black like tar /
asphalt. Blood pressure 90/50 mm Hg, and hemoglobin levels 10 g / dl. What are the priority
actions taken for the patient?
a.Keeps skin clean and dry
b.Check feces that have blood
c.Do the left limb ROM exercise
d. Raise the head of the bed to 30 degrees
e. Doing the restrain on the feet and hands

4. A 50-year-old woman presents to IRD with complaints of left front chest pain that does not
decrease with rest. Pain does not spread to other body parts and can be appointed. Vital signs
show a temperature of 38.6 degrees Celsius, a pulse frequency of 90 x / min. The client is
afraid that he has coronary heart disease and is just lying in bed. What is the main nursing
diagnosis in this case?
a. Acute pain
b.Herpertermi
c. Perfusion disorders
d. Activity intolerance
e. Sleep disturbance
5. A mother came to the clinic clinic, complaining of dizziness and pain in the stitches in her
drinker after giving birth 1 week ago. The examination results showed a clean perineum, red
color, 20 cc amount, foul odor. Warnavulva reddish, swollen, there is a liquid that comes out
of the perinium suture, and perinium skin that is sewn is less integrated, Blood pressure: 110
/ 70mmHg, S: 37.3 degrees Celsius What is the nursing problem that best suits the above
case?
a. Damage to the integrity of the skin
b. Activity intolerance
c. Lack of knowledge
d.Risk of infection
e. Acute pain

6.