NCLEX 形式の優先順位の決定と委任：直前対策パック

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。

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1公式と解法

優先順位の決定と委任

解き方

  1. 何もしなければ、最も早く患者に害が及ぶのは何かを考えます。
  2. ABC（心停止では C-A-B）を適用し、次にマズローの欲求を考えます：生理的欲求は安全の欲求より先、安全の欲求は心理的欲求より先です。
  3. 選択肢を比較します：急性は慢性より先、不安定は安定より先、予期しないものは予期されるものより先、全身は局所より先。そして各所見を患者のベースラインと照らします。
  4. 緊急でない限り、行動する前にアセスメントします。緊急の場合は、他の対応の前提となる手順を選びます。
  5. 委任では、5つの権利（業務、状況、人、指示、監督）を確認します。アセスメント、指導、評価は看護師（RN）が行います。

感染管理と患者の安全

解き方

  1. すべての患者に標準予防策から始めます：手指衛生、予想される曝露に応じた個人防護具（PPE）、安全な鋭利器材の扱い。
  2. 経路に応じて予防策を追加します：接触（ガウン、手袋）、飛沫（サージカルマスク）、空気（N95、陰圧室）。
  3. 滅菌物は滅菌のまま保ちます：疑わしければ滅菌ではありません。拭かずに交換します。
  4. 環境内の害を防ぎます：転倒対策、身体拘束は最後の手段、火災には RACE と PASS。
  5. 与薬の権利、2つの識別子、ハイリスク薬の追加の安全対策を確認し、エラーやヒヤリハットを報告します。

検査値と電解質

解き方

  1. 値を検査室独自の基準範囲と比べ、次に患者のベースラインと推移と比べます。
  2. 検体を確認します：溶血、遅れ、点滴の近くでの採血は、誤った結果の原因になります。
  3. 値を、典型的な徴候と、その原因となる薬剤や状態に結びつけます。
  4. 相互作用を探します：低カリウム血症や低マグネシウム血症はジゴキシン中毒を増強し、脱水はリチウムを上昇させます。
  5. 患者に対応します：アセスメントし、血中濃度が危険なら薬を保留し、パニック値は復唱して処方者に報告します。

内科外科看護：循環器と呼吸器

解き方

  1. 問題を言い当てます：ポンプ失調、動脈の閉塞、リズム、血栓、気道の狭窄、感染、または機器の問題。
  2. まず危険なサインを確認します：低酸素、低血圧、胸痛、新たな錯乱、冷たく脈の触れない手足。
  3. 酸素は患者に合わせます：大多数は94～98%、CO₂ 貯留のリスクがある人は88～92%。
  4. 各薬剤を、その検査とリスクに結びつけます：ワルファリンと INR、ヘパリンと aPTT・血小板、利尿薬とカリウム。
  5. 安全な最初の対応を選び、その後にエスカレーションして再評価します。

内科外科看護：神経、内分泌、腎臓

解き方

  1. 新たな錯乱、脱力、けいれんのあるすべての患者で血糖を確認します。
  2. 意識レベルを脳の異常の最も早い警告サインとして使います。瞳孔やクッシング三徴は遅れて現れます。
  3. 糖尿病の緊急事態では、DKA（ケトン、アシドーシス）と HHS（非常に高い浸透圧、脱水）を区別し、まず輸液を行います。
  4. ナトリウムと水分については、ADH が過剰（SIADH）か不足（DI）かを判断し、慢性の変化はゆっくり補正します。
  5. 腎臓の問題では、原因を腎前性、腎性、腎後性に分け、カリウムと水分に注意します。

内科外科看護：消化器、周術期、がん

解き方

  1. 何が隠れているかを考えます：体内出血、発熱のない感染、正常な SpO₂ の陰にある換気低下。
  2. 術後の時間経過で合併症を絞り込みます：数時間なら出血、数日なら胸部の問題、それ以降は創傷や縫合不全の問題。
  3. 疼痛は、アセスメントし、多角的鎮痛で治療し、再評価します。オピオイドを使うたびに鎮静をモニターします。
  4. がん患者では、最低値（ナディア）の時期の体調不良はすべて好中球減少性敗血症として扱い、腫瘍学的な緊急事態を把握しておきます。
  5. 熱傷では、II度とIII度の部分だけを数え、パークランドの時計は受傷時から始め、尿量に合わせて調整します。

2演習問題

1.優先順位の決定と委任ふつう

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

  1. ACheck the blood glucose and ketones and contact the provider
  2. BStop all insulin until the patient is able to eat normally again
  3. CWait until tomorrow to see if the vomiting settles
  4. DEncourage a large meal to settle the stomach
2.優先順位の決定と委任むずかしい

A patient is admitted with suspected meningococcal meningitis. Which precautions are needed until treatment has been given for long enough?

  1. AAirborne precautions
  2. BDroplet precautions
  3. CContact precautions only
  4. DStandard precautions only
3.感染管理と患者の安全ふつう

A patient is on seizure precautions. Which equipment should be ready at the bedside?

  1. AWorking suction and oxygen equipment
  2. BA tongue blade to put between the teeth
  3. CAn ice pack to place on the forehead
  4. DRestraints ready for all four limbs
4.感染管理と患者の安全むずかしい

During bedside handoff, the patient says, “I’m allergic to sulfa drugs,” but no allergy is recorded. What should the nurse do?

  1. ATell the patient that sulfa drugs are always safe
  2. BWait until the patient is discharged to update the record
  3. CIgnore it, because the electronic record is more reliable than the patient’s memory
  4. DClarify the reaction, update the allergy record and tell the prescriber
5.検査値と電解質ふつう

肝硬変の患者のアルブミンが 2.2 g/dL（22 g/L）です。最も関連しそうな所見はどれですか？

  1. A浮腫と腹水
  2. B高カリウム血症
  3. C尿量の増加
  4. D高血圧
6.検査値と電解質むずかしい

A nursing student has a positive interferon-gamma release assay (IGRA) for tuberculosis, no symptoms and a normal chest X-ray. What does this most likely mean?

  1. AA false result, as the test does not detect TB
  2. BPast BCG vaccination only, with no infection
  3. CActive pulmonary TB, which is contagious
  4. DLatent TB infection, which is not contagious
7.臨床看護学ふつう

Which group of symptoms suggests hypercalcaemia?

  1. AWeight gain, feeling cold and a slow pulse
  2. BThirst, constipation, confusion and abdominal pain
  3. CTingling lips, muscle cramps and spasms of the hands and feet
  4. DSweating, tremor and sudden hunger
8.臨床看護学むずかしい

A patient with small cell lung cancer has hyponatraemia, concentrated urine and no signs of dehydration. Which condition and first measure fit best?

  1. ADiabetes insipidus, managed with extra fluids
  2. BSIADH, often managed first with fluid restriction
  3. CCushing's syndrome, managed with potassium
  4. DDehydration, managed with an IV fluid bolus
9.内科外科看護：循環器と呼吸器ふつう

How does intermittent pneumatic compression help prevent DVT?

  1. AIt keeps the legs completely still to protect the veins
  2. BIt breaks up and dissolves clots that have already formed in the veins
  3. CIt squeezes the legs in cycles to push venous blood towards the heart
  4. DIt warms the legs gently so the blood becomes thinner and flows faster
10.内科外科看護：循環器と呼吸器むずかしい

A 74-year-old with atrial fibrillation, hypertension and diabetes asks why she needs an anticoagulant when she feels well. Which reply is best?

  1. AIt is needed only while she has palpitations
  2. BIt is given to lower her blood pressure
  3. CThe anticoagulant will stop the irregular heartbeat for good
  4. DHer risk of stroke is high, and an anticoagulant lowers it
11.内科外科看護：神経、内分泌、腎臓ふつう

After pressing the plunger of an insulin pen, what should the patient do?

  1. AKeep the needle in the skin for about 10 seconds
  2. BLeave the needle on the pen for the next injection
  3. CInject a second dose straight away to be sure
  4. DPull the needle out at once and rub the site firmly
12.内科外科看護：神経、内分泌、腎臓むずかしい

Why might a frail 88-year-old with type 2 diabetes have a less strict HbA1c target?

  1. ABecause diabetes cannot damage older people
  2. BBecause older people cannot use any glucose medicines
  3. CTo save money on blood tests and drugs
  4. DTo reduce the risk of hypos, falls and confusion
13.内科外科看護：消化器、周術期、がんふつう

What is the main treatment for a venous leg ulcer with an adequate arterial supply?

  1. ACompression therapy
  2. BKeeping the leg hanging down all day
  3. CStrong oral antibiotics for all ulcers
  4. DSurgery to amputate the limb
14.内科外科看護：消化器、周術期、がんむずかしい

Just after extubation in recovery, a patient develops a high-pitched noise on breathing in, with falling SpO₂. What should the nurse do first?

  1. ACall for help, give 100% oxygen and use a jaw thrust
  2. BSit the patient up and give a drink of water
  3. CWait a few minutes to see if it passes
  4. DGive an opioid to calm the patient's breathing and reduce anxiety

3溶液

1.優先順位の決定と委任

答え: A · Check the blood glucose and ketones and contact the provider

これが答えになる理由

Vomiting in type 1 diabetes can lead quickly to diabetic ketoacidosis. Glucose and ketones are checked and the provider is contacted; insulin is usually not stopped completely during illness.

答え

A · Check the blood glucose and ketones and contact the provider
2.優先順位の決定と委任

答え: B · Droplet precautions

これが答えになる理由

Neisseria meningitidis spreads by respiratory droplets, so a surgical mask is worn within close range. Droplet precautions continue until the patient has received effective antibiotics for about 24 hours.

答え

B · Droplet precautions
3.感染管理と患者の安全

答え: A · Working suction and oxygen equipment

これが答えになる理由

Suction and oxygen are kept ready to manage secretions and support breathing during or after a seizure. Nothing is put in the mouth, and restraints are not used because they can cause injury.

答え

A · Working suction and oxygen equipment
4.感染管理と患者の安全

答え: D · Clarify the reaction, update the allergy record and tell the prescriber

これが答えになる理由

Bedside handoff lets patients correct errors. The nurse asks about the reaction, updates the record and alerts the prescriber and pharmacy so current and future orders can be checked.

答え

D · Clarify the reaction, update the allergy record and tell the prescriber
5.検査値と電解質

答え: A · 浮腫と腹水

これが答えになる理由

アルブミンは、血管内に水分を保つ膠質浸透圧の大部分をもたらします。低下すると、水分が組織や腹部に漏れ出し、肝硬変では門脈圧亢進とともに、浮腫と腹水を起こします。確認に用いた資料: Albumin Blood Test · MedlinePlus (NIH) (2024)

答え

A · 浮腫と腹水
6.検査値と電解質

答え: D · Latent TB infection, which is not contagious

これが答えになる理由

A positive IGRA with no symptoms and a normal chest X-ray indicates latent TB infection, which cannot spread to others. Treatment of latent TB is often offered to prevent later active disease. The IGRA is much less likely than the skin test to give a false-positive result after BCG vaccination.確認に用いた資料: Tuberculosis Screening · MedlinePlus (NIH) (2026); PPD skin test · MedlinePlus (NIH) (2025)

答え

D · Latent TB infection, which is not contagious
7.臨床看護学

答え: B · Thirst, constipation, confusion and abdominal pain

これが答えになる理由

High calcium causes polyuria and thirst, constipation, abdominal pain, kidney stones and confusion. Tingling and cramps suggest low calcium instead.

答え

B · Thirst, constipation, confusion and abdominal pain
8.臨床看護学

答え: B · SIADH, often managed first with fluid restriction

これが答えになる理由

In SIADH, excess ADH makes the kidneys retain water, so blood sodium is diluted while urine is concentrated. Small cell lung cancer is a classic cause; fluid restriction is a common first step.

答え

B · SIADH, often managed first with fluid restriction
9.内科外科看護：循環器と呼吸器

答え: C · It squeezes the legs in cycles to push venous blood towards the heart

これが答えになる理由

Inflatable sleeves around the calves or feet inflate and deflate in cycles, increasing venous return and reducing stasis. They are used when anticoagulation is unsuitable or alongside it. They are not used on a leg with a known DVT or severe arterial disease.

答え

C · It squeezes the legs in cycles to push venous blood towards the heart
10.内科外科看護：循環器と呼吸器

答え: D · Her risk of stroke is high, and an anticoagulant lowers it

これが答えになる理由

In AF, blood stasis in the left atrium causes clots that can travel to the brain. Scores such as CHA₂DS₂-VASc (age, hypertension, diabetes, female sex and others) estimate stroke risk; her score is high. Anticoagulation reduces stroke risk but does not change the rhythm.

答え

D · Her risk of stroke is high, and an anticoagulant lowers it
11.内科外科看護：神経、内分泌、腎臓

答え: A · Keep the needle in the skin for about 10 seconds

これが答えになる理由

Holding the needle in place for around 10 seconds (or as the manufacturer advises) lets the full dose be delivered. A new needle is used for each injection, and the site should not be massaged.

答え

A · Keep the needle in the skin for about 10 seconds
12.内科外科看護：神経、内分泌、腎臓

答え: D · To reduce the risk of hypos, falls and confusion

これが答えになる理由

In frail older adults, tight control brings little long-term benefit and a high risk of hypoglycaemia, which can cause falls, fractures and confusion. Targets are individualised to balance safety and quality of life.

答え

D · To reduce the risk of hypos, falls and confusion
13.内科外科看護：消化器、周術期、がん

答え: A · Compression therapy

これが答えになる理由

Graduated compression reduces venous hypertension and oedema and speeds healing. Leg elevation, exercise and treating the underlying vein disease also help.

答え

A · Compression therapy
14.内科外科看護：消化器、周術期、がん

答え: A · Call for help, give 100% oxygen and use a jaw thrust

これが答えになる理由

Stridor after extubation suggests laryngospasm or another upper airway obstruction. The nurse calls for help, applies high-flow oxygen and airway manoeuvres, and the anaesthetist may give drugs or reintubate.

答え

A · Call for help, give 100% oxygen and use a jaw thrust

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