公式集、全トピックの解法の要点、14 問の演習問題。完全な解答は巻末にあります。
A swimmer is found unresponsive after diving into shallow water. Which method should the nurse use to open the airway?
A patient with severe sepsis starts oozing blood from IV sites and the gums, and bruises appear on the skin. What should the nurse suspect?
A patient is admitted to an inpatient mental health unit. Why are personal belongings checked?
A flexible bronchoscope contacts mucous membranes but does not enter sterile tissue. Which level of processing is required at a minimum between patients?
In the third trimester of pregnancy, a woman's alkaline phosphatase (ALP) is about twice the usual adult range, and the other liver tests are normal. What is the best interpretation?
A patient has eaten very little for 2 weeks and has received broad-spectrum antibiotics. The INR is now 2.3 without warfarin, and the platelets are normal. What is the most likely cause?
Why can a very low serum albumin contribute to oedema?
A patient with severe sepsis starts bleeding from cannula sites and the gums, with a low platelet count and prolonged clotting times. What is most likely?
After thrombolysis for a myocardial infarction, which complication is the nurse most concerned to detect?
Which method best confirms that an endotracheal tube is in the trachea?
A stroke patient with dysphagia has been started on a modified diet. Which action best reduces the risk of aspiration?
A patient with gastroparesis has hypos soon after their meal-time insulin, then high glucose several hours later. What is the best explanation?
肝硬変における、ナトリウム制限とスピロノラクトンの役割は何ですか？
化学療法の10日後、患者の体温は37.6 °Cですが、寒気と不調を感じており、脈拍112/分、血圧95/60 mmHgです。正しい対応はどれですか？
答え: A · Jaw thrust, keeping the head and neck in line
A diving injury may damage the cervical spine. A jaw thrust opens the airway with little neck movement; if it fails, the airway still takes priority.
答え: C · Disseminated intravascular coagulation (DIC)
In DIC, widespread clotting uses up platelets and clotting factors, causing bleeding from many sites. It is a serious complication of sepsis that needs urgent escalation.
答え: A · To remove items that could be used to harm self or others
Belongings are searched with the patient, according to policy, for items such as sharp objects, cords, drugs and lighters. These are stored safely to reduce the risk of self-harm or violence.
答え: D · High-level disinfection
Items that touch mucous membranes or non-intact skin are semi-critical and need at least high-level disinfection after thorough cleaning. Inadequate reprocessing of endoscopes has caused outbreaks.
答え: C · A normal rise from placental ALP
The placenta produces ALP, so serum ALP normally rises in late pregnancy. With normal bilirubin, ALT and AST, this is expected. Symptoms such as severe itching or raised bile acids would need further review.確認に用いた資料: Alkaline Phosphatase · MedlinePlus (NIH) (2024)
答え: D · Vitamin K deficiency
Vitamin K comes from the diet and from gut bacteria. Poor intake plus antibiotics can cause vitamin K deficiency, which lowers factors II, VII, IX and X and prolongs the PT/INR. Vitamin K replacement corrects it.確認に用いた資料: Vitamin K Deficiency in Neonates and Adults (StatPearls) · StatPearls (NCBI Bookshelf) (2026); Prothrombin time (PT) · MedlinePlus (NIH) (2025)
答え: D · It lowers the oncotic pressure that holds fluid in the blood vessels
Albumin creates oncotic pressure, drawing fluid into the capillaries. When it is low, as in liver disease, nephrotic syndrome or malnutrition, fluid leaks into the tissues.
答え: B · Disseminated intravascular coagulation
In DIC, widespread activation of clotting consumes platelets and clotting factors, causing both small clots and bleeding. Treating the underlying cause and replacing blood products as needed are key.
答え: B · Bleeding, including a sudden change in neurological status
The main risk of thrombolysis is bleeding, from puncture sites, gums or the gut, and most seriously intracranial haemorrhage. The nurse monitors puncture sites, vital signs and neurological status and minimises invasive procedures. Reperfusion arrhythmias are also common.
答え: B · A sustained waveform on capnography
A sustained exhaled carbon dioxide waveform confirms tracheal placement. Misting and chest movement can be misleading, and skin colour changes late. A chest X-ray shows the depth of the tube but does not prove it is in the trachea.
答え: D · Sit the patient fully upright for meals and for a while afterwards
Sitting upright during and after meals helps food pass safely and reduces reflux and aspiration. Small mouthfuls, unhurried feeding and the textures advised by the speech and language therapist are also important.
答え: D · Food is absorbed slowly, so the insulin peaks before the glucose rises
Delayed gastric emptying means carbohydrate reaches the blood later than expected. The insulin acts too early, causing a hypo, and glucose rises later. The prescriber may change the timing, for example giving the insulin after the meal.
答え: D · ナトリウムと水分の貯留を減らし、腹水を抑えること
肝硬変では、二次性のアルドステロン症がナトリウムと水分の貯留を起こします。ナトリウム制限とアルドステロン拮抗薬のスピロノラクトン（しばしばループ利尿薬と併用）が腹水を減らします。スピロノラクトンは、高カリウム血症と女性化乳房を起こしうります。
答え: B · 好中球減少性敗血症の可能性として扱う。1時間以内に抗菌薬を静注する
予想されるナディアの時期に具合の悪い患者は、高熱がなくても好中球減少性敗血症として扱います。悪寒戦慄、頻脈、低血圧は警告のサインです。血球数を待たずに、血液培養を採取し、1時間以内に経験的な抗菌薬の静注を開始します。解熱薬は発熱を隠すことがあり、アセスメントを遅らせてはいけません。
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