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

Which telephone call should a clinic nurse return first?

  1. AA parent of a 6-week-old with a temperature of 38.3 °C
  2. BA parent of a 5-year-old with a runny nose for two days
  3. CAn adult who wants to move a routine blood test appointment
  4. DAn adult asking for a repeat prescription for a statin
2.優先順位の決定と委任むずかしい

On a cardiac step-down unit, which patient should the nurse assess first?

  1. ASix hours after a coronary stent, new chest pain with ST elevation on the monitor
  2. BDay 2 after a pacemaker insertion, asking when the wound dressing will be changed
  3. CAtrial fibrillation on warfarin with an INR of 2.6 this morning
  4. DHeart failure, weight up 0.5 kg since yesterday, no breathlessness at rest
3.感染管理と患者の安全ふつう

A patient is receiving opioids for pain. Which sign usually comes before opioid-induced respiratory depression?

  1. AIncreasing sedation
  2. BDilated pupils
  3. CDiarrhea
  4. DRising blood pressure
4.感染管理と患者の安全むずかしい

急性の下痢で入院した患者に C. difficile 感染症が疑われます。検査結果は未着です。接触予防策はいつ開始しますか？

  1. A下痢が3日続いた後
  2. B検査結果を待たず、直ちに
  3. C患者が発熱したときだけ
  4. D検査結果が陽性で返ってきたときだけ
5.検査値と電解質ふつう

A patient who is breathless during a transfusion has hypotension, fever and bilateral lung infiltrates, with no signs of fluid overload. Which complication is most likely?

  1. AA simple allergic reaction with hives
  2. BA mild febrile nonhemolytic reaction
  3. CTransfusion-related acute lung injury (TRALI)
  4. DTransfusion-associated circulatory overload
6.検査値と電解質むずかしい

A patient without symptoms has a finger-stick glucose of 340 mg/dL (18.9 mmol/L). The previous values were normal, and the patient has just peeled an orange. What should the nurse do first?

  1. AGive a correction dose of insulin for a glucose of 340 mg/dL
  2. BHave the patient wash and dry their hands, then repeat the test
  3. CAsk the laboratory to measure HbA1c from the same drop of blood
  4. DReport the result as a new diagnosis of diabetes mellitus
7.臨床看護学ふつう

A patient with pneumonia is breathless and coughing up thick sputum. Which nursing measure helps most with breathing?

  1. ADiscouraging coughing to save energy
  2. BSitting the patient upright and supporting them to clear secretions
  3. CRestricting all oral fluids
  4. DLying the patient flat so that they can rest and conserve energy
8.臨床看護学むずかしい

A patient with long-standing COPD has an arterial blood gas with pH 7.37, a raised PaCO2 and a raised bicarbonate. How is this best described?

  1. ACompensated respiratory acidosis
  2. BAcute respiratory acidosis
  3. CUncompensated metabolic alkalosis
  4. DMixed metabolic and respiratory alkalosis
9.内科外科看護：循環器と呼吸器ふつう

How does digoxin help a patient with atrial fibrillation and heart failure?

  1. AIt slows AV node conduction and increases contractility
  2. BIt speeds conduction through the AV node to the ventricles
  3. CIt dissolves clots that have formed in the left atrium
  4. DIt lowers potassium to stabilise the heart
10.内科外科看護：循環器と呼吸器むずかしい

A nurse has four cardiac patients. Which one should be seen first?

  1. AA patient with heart failure whose weight is 0.3 kg up on yesterday's morning weight
  2. BA patient with AF and a heart rate of 86/min who is due an apixaban dose this morning
  3. CA patient with angina whose chest pain has not eased with rest and who is sweating
  4. DA patient after a radial angiogram asking when they can eat
11.内科外科看護：神経、内分泌、腎臓ふつう

Why are patients on haemodialysis vaccinated against hepatitis B?

  1. AThe vaccine is needed to make the dialyser work
  2. BHepatitis B vaccine improves the fistula flow
  3. CThe vaccine lowers the potassium level
  4. DShared dialysis units carry a higher infection risk
12.内科外科看護：神経、内分泌、腎臓むずかしい

A large pituitary tumour presses on the optic chiasm. Which visual field defect is most typical?

  1. ALoss of the outer half of the field in both eyes
  2. BComplete blindness in one eye only
  3. CLoss of the inner half of the field in both eyes
  4. DLoss of central vision in both eyes
13.内科外科看護：消化器、周術期、がんふつう

Which complication is more typical of Crohn's disease than of ulcerative colitis?

  1. AFistulas between the bowel and other organs
  2. BDisease that is cured by removing the colon
  3. CBleeding only from the rectum
  4. DInflammation limited to the rectal lining
14.内科外科看護：消化器、周術期、がんむずかしい

A patient is splashed in the eye with an alkaline cleaning product. What is the first action?

  1. ACover the eye with a pad and wait for a doctor to examine it first
  2. BIrrigate the eye at once with large volumes of water or saline
  3. CAsk the patient to rub the eye to clear it
  4. DAdd a few drops of vinegar to neutralise it

3溶液

1.優先順位の決定と委任

答え: A · A parent of a 6-week-old with a temperature of 38.3 °C

これが答えになる理由

A fever in an infant under about 3 months old needs urgent assessment, because serious bacterial infection is more likely and signs can be subtle. The other calls are routine.

答え

A · A parent of a 6-week-old with a temperature of 38.3 °C
2.優先順位の決定と委任

答え: A · Six hours after a coronary stent, new chest pain with ST elevation on the monitor

これが答えになる理由

New chest pain with ST elevation after a stent suggests the stent may have blocked, causing an acute myocardial infarction. This is an emergency; the other findings are within target or routine.

答え

A · Six hours after a coronary stent, new chest pain with ST elevation on the monitor
3.感染管理と患者の安全

答え: A · Increasing sedation

これが答えになる理由

Sedation increases before respiratory depression occurs, so sedation levels are checked regularly along with breathing. A patient who is getting harder to wake needs the opioid held and the prescriber informed.

答え

A · Increasing sedation
4.感染管理と患者の安全

答え: B · 検査結果を待たず、直ちに

これが答えになる理由

検査結果を待つ間も患者は芽胞を広げうるため、疑った時点で予防策を開始します。患者を個室に入れて接触予防策を行い、石けんと流水による手洗いを用います。

答え

B · 検査結果を待たず、直ちに
5.検査値と電解質

答え: C · Transfusion-related acute lung injury (TRALI)

これが答えになる理由

TRALI is acute lung injury within 6 hours of transfusion, caused by donor antibodies activating neutrophils in the lungs. It causes hypoxia, bilateral infiltrates and often hypotension and fever. TACO, in contrast, causes hypertension and signs of fluid overload.

答え

C · Transfusion-related acute lung injury (TRALI)
6.検査値と電解質

答え: B · Have the patient wash and dry their hands, then repeat the test

これが答えになる理由

Sugar residue on the fingers can give a falsely high finger-stick result. The hands are washed with soap and water and dried, and the test repeated. If the value is still high, it is confirmed and reported. Treating a false result could cause hypoglycemia.

答え

B · Have the patient wash and dry their hands, then repeat the test
7.臨床看護学

答え: B · Sitting the patient upright and supporting them to clear secretions

これが答えになる理由

An upright position improves lung expansion, and adequate fluids, deep breathing and coughing help clear sputum. Oxygen is given to target saturations if needed.

答え

B · Sitting the patient upright and supporting them to clear secretions
8.臨床看護学

答え: A · Compensated respiratory acidosis

これが答えになる理由

Chronic CO2 retention is offset by the kidneys retaining bicarbonate, bringing the pH back to normal. A normal pH with high PaCO2 and high bicarbonate is a compensated respiratory acidosis.

答え

A · Compensated respiratory acidosis
9.内科外科看護：循環器と呼吸器

答え: A · It slows AV node conduction and increases contractility

これが答えになる理由

Digoxin inhibits the Na⁺/K⁺-ATPase, raising intracellular calcium and contractility, and increases vagal tone, slowing AV conduction and the ventricular rate. It controls symptoms but does not reduce stroke risk, so anticoagulation is still needed in AF.

答え

A · It slows AV node conduction and increases contractility
10.内科外科看護：循環器と呼吸器

答え: C · A patient with angina whose chest pain has not eased with rest and who is sweating

これが答えになる理由

Chest pain that does not settle with rest, especially with sweating, suggests an acute coronary syndrome and needs immediate assessment and a 12-lead ECG. A controlled heart rate in AF, a very small weight change and a question about eating are not urgent.

答え

C · A patient with angina whose chest pain has not eased with rest and who is sweating
11.内科外科看護：神経、内分泌、腎臓

答え: D · Shared dialysis units carry a higher infection risk

これが答えになる理由

Haemodialysis involves repeated vascular access in a shared unit, which raises the risk of blood-borne infection. Vaccination, screening and strict infection control protect patients and staff.

答え

D · Shared dialysis units carry a higher infection risk
12.内科外科看護：神経、内分泌、腎臓

答え: A · Loss of the outer half of the field in both eyes

これが答えになる理由

The chiasm carries crossing fibres from the nasal retinas, which see the temporal (outer) fields. Compression causes a bitemporal hemianopia. Patients may bump into objects at their sides.

答え

A · Loss of the outer half of the field in both eyes
13.内科外科看護：消化器、周術期、がん

答え: A · Fistulas between the bowel and other organs

これが答えになる理由

Transmural inflammation in Crohn's disease can create fistulas, abscesses and strictures. Ulcerative colitis is mucosal, and removing the colon and rectum is curative.

答え

A · Fistulas between the bowel and other organs
14.内科外科看護：消化器、周術期、がん

答え: B · Irrigate the eye at once with large volumes of water or saline

これが答えになる理由

Alkali burns can cause severe, deep eye damage. Immediate, prolonged irrigation, checking the pH, and urgent ophthalmology review are needed. Neutralising agents are not used.

答え

B · Irrigate the eye at once with large volumes of water or saline

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