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。
デイルームで食事をしていた成人の患者が、突然のどをつかみ、話すことも、呼吸することも、咳をすることもできません。看護師が最初にすることは何ですか？
An older patient has bruises of different ages and seems frightened when a relative visits. What is the nurse’s priority?
Why are blood cultures usually taken from two separate venipuncture sites?
A nurse teaches a patient with neutropenia about preventing infection at home. Which statement shows a need for further teaching?
Why is a baseline platelet count taken before starting heparin therapy?
An older adult with type 2 diabetes is drowsy and very dehydrated. Glucose 920 mg/dL (51 mmol/L), serum osmolality 350 mOsm/kg, pH 7.36, urine ketones negative or trace. Which condition fits best?
Compared with a colostomy, a patient with an ileostomy is at greater risk of:
A patient is taught to self-inject low-molecular-weight heparin. Which statement shows a need for further teaching?
Before the first treatment dose of a low-molecular-weight heparin for a PE, what does the nurse need to make sure of?
Two days after a coronary stent, a patient on aspirin and ticagrelor has black, tarry stools and feels faint on standing. What should the nurse do?
尿崩症とSIADHを最もよく区別する尿所見はどれですか？
長期間、高用量のプレドニゾロンを服用している患者が、腸の手術の3日後です。腹痛は軽いと訴えるだけですが、心拍数が115/分に上がり、体温は37.4 °Cです。看護師が特に懸念すべきなのはなぜですか？
大手術の後の最初の数日間、「必要時」の投与より定期的（スケジュール化）な鎮痛が好まれることが多いのはなぜですか？
Four hours after surgery, a catheterised patient's urine output has been 10 mL/h for two hours. Vital signs are stable. What should the nurse check first?
答え: D · 応援を呼び、背部叩打と腹部突き上げを行う
話すことも、呼吸することも、咳をすることもできない成人には、重度の気道閉塞があります。欧州蘇生協議会などの蘇生ガイドラインでは、背部叩打を最大 5 回、続いて腹部突き上げを最大 5 回行い、異物が出るまで繰り返すことが推奨されています。腹部突き上げから始めるガイドラインもあります。患者の反応がなくなったら CPR を開始します。盲目的に指でかき出すと、異物をさらに奥へ押し込むおそれがあります。
答え: D · Ensure the patient’s safety, document the findings and report as required
Unexplained bruises of different ages and fear of a carer can suggest abuse. The nurse makes sure the patient is safe, documents objectively and reports according to law and policy.
答え: C · To help tell a true infection from skin contamination
If the same organism grows from both sets, it is more likely to be a true bloodstream infection. Growth in only one set may be contamination from the skin.
答え: A · “I can clean the cat’s litter box if I wear a face mask.”
Immunocompromised patients should avoid cleaning litter boxes and other animal waste, because of organisms such as Toxoplasma. Another person should do it. The other statements are correct.
答え: C · So a later fall from heparin-induced thrombocytopenia is detected
Heparin-induced thrombocytopenia is diagnosed partly by a fall of about 50% or more from the baseline count, usually 5–14 days after starting. A baseline count and regular checks make this possible.確認に用いた資料: Heparin-Induced Thrombocytopenia · StatPearls (NCBI Bookshelf) (2023)
答え: C · Hyperosmolar hyperglycemic state (HHS)
HHS causes extreme hyperglycemia and high osmolality with severe dehydration, but enough insulin is present to prevent significant ketosis, so the pH is near normal. DKA has ketones and acidosis; SIADH has low osmolality.確認に用いた資料: Ketoacidosis · StatPearls (NCBI Bookshelf) (2023); Osmolality blood test · MedlinePlus (NIH) (2025)
答え: C · Dehydration and electrolyte loss from liquid output
Ileostomy output is liquid because it bypasses the colon, which normally absorbs water and salts. Patients must drink enough and watch for signs of dehydration, especially in hot weather or illness.
答え: A · "I will rub the area firmly after the injection."
Rubbing the site after an anticoagulant injection increases bruising and is avoided. Rotating sites, injecting subcutaneously and reporting bleeding are correct.
答え: B · An accurate, recent body weight is recorded
Treatment doses of LMWH are based on body weight, so an accurate measured weight is essential. Renal function and platelet count are also checked before starting. Guessing the weight can lead to under- or overdosing.
答え: A · Check vital signs, report urgently and anticipate a blood count
Melaena with postural dizziness suggests upper gastrointestinal bleeding, a risk with dual antiplatelet therapy. The nurse assesses for shock, informs the team urgently and expects bloods, a group and save (type and screen) and possibly endoscopy. Stopping antiplatelets after a stent risks stent thrombosis, so the decision belongs to the medical and cardiology team.
答え: D · 尿崩症は薄い尿、SIADHは濃い尿
尿崩症では、ADHの作用の欠如により、血清ナトリウムが高く、大量の薄い尿（比重はしばしば1.005未満）が出ます。SIADHでは、ADHの過剰により、尿量が少なく濃い尿で、血清ナトリウムが低くなります。
答え: C · ステロイドは発熱、痛み、腹膜刺激症状を隠し、合併症を見えなくしうるから
長期のステロイドは発熱、痛み、腹壁の硬直を鈍らせるため、吻合部の縫合不全、膿瘍、穿孔は、頻脈のようなわずかな徴候だけで現れることがあります。看護師は十分にアセスメントし、早期に上申すべきです。これらの患者には、副腎クリーゼを防ぐため、手術の前後にステロイドのカバーも必要です。
答え: D · 薬の濃度が安定し、激しい痛みのピークを防げるから
予測できる持続的な術後の痛みは、定期的な多角的鎮痛（例えばパラセタモールと、安全な場合はNSAID）で管理し、突出痛には頓用の用量を併用するのが最善です。痛みと副作用は引き続き定期的にアセスメントします。
答え: C · That the catheter and tubing are not kinked or blocked
A sudden low output may be due to a kinked tube or blocked catheter. If drainage is normal, hypovolaemia or kidney injury is considered and the team is informed, with a fluid assessment.
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