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。
転倒予防の対応が必要な患者について、看護師が看護助手に委任すべき業務はどれですか？
Which patient needs airborne precautions rather than droplet precautions?
A patient cannot bear weight and cannot help with transfers. Which method is safest to move the patient from bed to chair?
A nurse floated to an unfamiliar unit is asked to manage a device they have never been trained to use. What should the nurse do?
A patient with type 1 diabetes has the flu, is eating little and has a glucose of 290 mg/dL (16.1 mmol/L). Which advice is correct?
In the first 24 hours after a major burn, which laboratory pattern is most expected?
Why should a urinary catheter drainage bag be kept below the level of the bladder?
A patient starting a DOAC is taught about missed doses. Which statement shows a need for further teaching?
A 70 kg patient has passed 20 mL of urine per hour for the last three hours. How should this be interpreted?
After an anaphylactic reaction to a bee sting that responded to adrenaline (epinephrine), a patient asks to go home immediately. Which advice is most appropriate?
Which picture fits Brown-Séquard syndrome?
During a water deprivation test for suspected diabetes insipidus, the patient loses more than 3% of body weight and becomes hypotensive. What should the nurse do?
Which monitoring is especially important for a patient receiving parenteral nutrition?
患者が陰圧閉鎖療法を受けています。ポンプが警報を発し、ドレッシングの密閉が失われました。最も適切な対応はどれですか？
答え: C · 計画どおり、2 時間ごとに患者をトイレに連れて行く
定時のトイレ誘導は、ケア計画に沿った定型的な業務です。転倒リスクの採点、介入の判断、指導には、看護の判断が必要です。
答え: A · A child with chickenpox (varicella)
Varicella spreads by the airborne route (and contact), so it needs an airborne infection isolation room. Influenza, pertussis and mumps are spread mainly by droplets.
答え: A · A mechanical lift used by enough trained staff
For a patient who cannot bear weight or help, a mechanical lift prevents injury to both patient and staff. Lifting under the arms can injure the shoulders, and pivot transfers need weight bearing.
答え: A · Tell the charge nurse and ask for help or a change of assignment
Accepting a task beyond one’s competence puts the patient at risk. The nurse explains the limit to the charge nurse, who can arrange help, training or reassignment.
答え: D · Keep taking insulin and check blood or urine ketones
During illness, stress hormones raise glucose, so insulin is continued even when eating less. Glucose and ketones are checked often, fluids are taken, and the provider is contacted if ketones are moderate or high or vomiting prevents fluids.確認に用いた資料: Diabetes - when you are sick · MedlinePlus (NIH) (2026)
答え: C · High potassium and high hematocrit
Early after a burn, damaged cells release potassium, and plasma shifts into the tissues, which concentrates the blood and raises the hematocrit. Later, as fluid returns and the kidneys excrete potassium, hypokalemia can develop.確認に用いた資料: High potassium level · MedlinePlus (NIH) (2025)
答え: C · To prevent urine flowing back into the bladder
Keeping the bag below the bladder allows drainage and prevents backflow, which reduces infection risk. The bag should also not touch the floor.
答え: B · "If I forget a dose, I'll take two the next day to catch up."
Doubling up on an anticoagulant increases the bleeding risk. Patients follow the specific missed-dose advice for their drug and never take a double dose.
答え: A · Below 0.5 mL/kg/h, suggesting poor kidney perfusion
A urine output below about 0.5 mL/kg/h (35 mL/h for 70 kg) for several hours is oliguria and may indicate hypovolaemia, shock or acute kidney injury. It should be reported along with the other observations, and the catheter checked for blockage.
答え: C · Stay for observation, then go home with an adrenaline auto-injector and teaching
Biphasic reactions can occur hours after the first reaction resolves, so patients are observed for a period determined by severity and local guidance. Before discharge they receive adrenaline auto-injectors with training, a written plan and referral to an allergy service.
答え: C · Weakness on the same side and loss of pain on the opposite side
Damage to one side of the spinal cord, often from a stab wound, causes motor loss and loss of proprioception on the same side, and loss of pain and temperature on the opposite side. The pain fibres cross soon after entering the cord.
答え: B · Stop the test and inform the doctor
In DI, the patient keeps passing dilute urine despite fluid restriction and can become dangerously dehydrated. Significant weight loss, hypotension or a high sodium are reasons to stop the test and get medical review.
答え: B · Blood glucose and signs of line infection
PN can cause hyperglycaemia and electrolyte disturbance, and the central line is a route for bloodstream infection. Glucose, electrolytes, fluid balance, weight and temperature are monitored closely.
答え: A · 密閉を回復する。時間内にできなければ、湿潤ドレッシングに替える
NPWTには気密な密閉が必要です。密閉または吸引が失われ、速やかに（多くのガイドラインでは約2時間以内に）回復できない場合は、感染のリスクを減らすため、フォームを取り除いて標準的なドレッシングに替えます。安全な時間は、製造元と地域のガイダンスで定められています。
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