1公式と解法
優先順位の決定と委任
解き方
- 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。
- 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。
- 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。
- 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。
- 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
- 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。
- 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）。
- 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。
- 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。
- 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
- 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。
- 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。
- 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。
- 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。
- 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
- 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。
- 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。
- 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%。
- 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。
- 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
- 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。
- 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。
- 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。
- 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。
- 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
- 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。
- 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。
- 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。
- 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。
- 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 patient is at the highest risk of falling?
- AA 45-year-old with asthma who is alert and independent
- BAn 84-year-old taking a diuretic who has fallen before and gets up at night
- CA 30-year-old after an appendectomy who walks with steady steps
- DA 60-year-old admitted for chest pain that has since been ruled out by tests
2.優先順位の決定と委任むずかしい
A patient on peritoneal dialysis has cloudy fluid draining out and abdominal pain. What does this most likely mean?
- APeritonitis, which needs prompt reporting and a fluid sample
- BA normal finding at the end of each exchange
- CToo much fluid left in the abdomen after the drain
- DConstipation that will settle with a laxative later today or tomorrow
3.感染管理と患者の安全ふつう
The laboratory calls with a critical lab result by phone. What should the nurse do?
- AWrite it down, read it back to confirm and report it to the provider promptly
- BRemember the value and enter it in the chart at the end of the shift
- CTell the patient the result first and then call the provider
- DWait for the printed report to arrive before telling the provider about it
4.感染管理と患者の安全むずかしい
Victims of a chemical spill arrive at the emergency department with liquid on their skin and clothing. What is the priority before they enter the building?
- ATake them straight into the resuscitation room so treatment is not delayed
- BDecontaminate them outside, with staff wearing appropriate PPE
- CTake a full history in the waiting room
- DGive them hospital gowns and seat them in triage
5.検査値と電解質ふつう
A patient's levothyroxine dose was changed today. When is the TSH usually rechecked?
- AAfter about 3 days
- BAfter about 6–8 weeks
- CAfter about 1 year
- DAfter about 24 hours
6.検査値と電解質むずかしい
A patient with chronic kidney disease stage 4 has a high phosphate, a low-normal calcium and a very high parathyroid hormone (PTH). What does this show?
- ASecondary hyperparathyroidism from CKD
- BPrimary hyperparathyroidism from a tumor
- CVitamin D toxicity from supplements
- DHypoparathyroidism after neck surgery
7.臨床看護学ふつう
意識のない糖尿病患者の血糖が 2.1 mmol/L で、静脈路がありません。何を投与できますか？
- A経口のブドウ糖タブレット
- B経口の果物ジュース
- Cグルカゴンの筋肉注射
- Dインスリンの皮下注射
8.臨床看護学むずかしい
A patient is recognised by the team as being in the last days of life. Which approach is correct?
- AReview and stop treatments that no longer help, and focus on comfort
- BStop all medicines, including pain relief and anti-sickness drugs
- CAvoid talking with the family about what is happening
- DContinue all routine blood tests and observations four-hourly
9.内科外科看護：循環器と呼吸器ふつう
末梢動脈疾患の患者が夜間に脚の痛みを訴えています。楽になる可能性のある体位はどれですか？
- Aベッドの端から脚を下に垂らす
- B脚を圧迫包帯で巻く
- C脚を枕の上で心臓より高く上げる
- D湯たんぽを足に直接当てる
10.内科外科看護：循環器と呼吸器むずかしい
A ventilated patient is coughing, and the high-pressure alarm sounds. Coarse sounds are heard over the trachea. What should the nurse do first?
- AAssess the patient and suction if secretions are present
- BIncrease the tidal volume on the ventilator to overcome it
- CTurn the alarm off and reassess the patient in an hour
- DDeflate the endotracheal tube cuff fully
11.内科外科看護：神経、内分泌、腎臓ふつう
Before surgery for a phaeochromocytoma, why is an alpha-blocker started before any beta-blocker?
- ABeta-blockers given first would make the tumour grow faster
- BThe order of the two drugs makes no difference
- CAlpha-blockers lower the blood glucose before surgery
- DA beta-blocker alone can cause a dangerous rise in BP
12.内科外科看護：神経、内分泌、腎臓むずかしい
An 84-year-old man became more confused a week after starting oxybutynin. Infection has been ruled out. What should the nurse suspect?
- AA symptom of a high potassium from the drug
- BAnticholinergic side effects of the drug
- CA sign that the drug dose is too low
- DNormal ageing that needs no review
13.内科外科看護：消化器、周術期、がんふつう
Why is pethidine (meperidine) generally avoided for regular pain relief?
- AA metabolite can build up and cause seizures
- BIt always causes severe diarrhoea
- CIt has no pain-relieving effect at all in adults
- DIt can only be given by mouth
14.内科外科看護：消化器、周術期、がんむずかしい
A patient asks whether to take their usual bisoprolol on the morning of surgery. What is the usual guidance?
- ATake it only after the operation is finished
- BStop it one week before any operation
- CTake a double dose to protect the heart
- DUsually continue it with a sip of water, unless told otherwise
3溶液
1.優先順位の決定と委任
答え: B · An 84-year-old taking a diuretic who has fallen before and gets up at night
これが答えになる理由
A previous fall is one of the strongest risk factors. Older age, diuretics and getting up at night to urinate add further risk, so this patient needs fall precautions.
B · An 84-year-old taking a diuretic who has fallen before and gets up at night
2.優先順位の決定と委任
答え: A · Peritonitis, which needs prompt reporting and a fluid sample
これが答えになる理由
Cloudy effluent with abdominal pain is a classic sign of peritonitis, a serious complication of peritoneal dialysis. The nurse reports it and sends a sample as prescribed so antibiotics can start.
A · Peritonitis, which needs prompt reporting and a fluid sample
3.感染管理と患者の安全
答え: A · Write it down, read it back to confirm and report it to the provider promptly
これが答えになる理由
Writing down and reading back critical results confirms they were heard correctly. The nurse then reports them promptly to the responsible provider and documents who was told and when.
A · Write it down, read it back to confirm and report it to the provider promptly
4.感染管理と患者の安全
答え: B · Decontaminate them outside, with staff wearing appropriate PPE
これが答えになる理由
Contaminated patients are decontaminated outside the department so the chemical is not brought inside to harm staff and other patients. Staff doing this wear PPE suited to the hazard.
B · Decontaminate them outside, with staff wearing appropriate PPE
5.検査値と電解質
答え: B · After about 6–8 weeks
これが答えになる理由
Levothyroxine has a half-life of about a week, so a steady state takes about 6 weeks. The TSH is therefore rechecked about 6–8 weeks after a dose change; checking earlier gives a misleading result.
B · After about 6–8 weeks
6.検査値と電解質
答え: A · Secondary hyperparathyroidism from CKD
これが答えになる理由
In CKD, phosphate retention and reduced activation of vitamin D lower calcium, which stimulates the parathyroid glands. The result is high PTH with high phosphate, causing bone disease. Phosphate binders, diet and active vitamin D are used.
A · Secondary hyperparathyroidism from CKD
7.臨床看護学
答え: C · グルカゴンの筋肉注射
これが答えになる理由
意識のない低血糖では、経口の処置は誤嚥の危険があります。筋注のグルカゴンは肝臓のグリコーゲンを放出させます。静脈路があればブドウ糖を静注します。
8.臨床看護学
答え: A · Review and stop treatments that no longer help, and focus on comfort
これが答えになる理由
When dying is recognised, non-beneficial interventions are stopped and anticipatory medicines for symptoms such as pain, agitation and secretions are prescribed. Clear communication with the patient and family is essential.
A · Review and stop treatments that no longer help, and focus on comfort
9.内科外科看護：循環器と呼吸器
答え: A · ベッドの端から脚を下に垂らす
これが答えになる理由
虚血性の安静時痛は、脚を下げると、重力により動脈血流が改善して、しばしば和らぎます。挙上は虚血を悪化させます。重大な動脈疾患では圧迫は禁忌で、直接の熱は、感覚が鈍く虚血した皮膚にやけどを負わせるおそれがあります。
10.内科外科看護：循環器と呼吸器
答え: A · Assess the patient and suction if secretions are present
これが答えになる理由
High-pressure alarms are caused by secretions, coughing, biting the tube, kinked tubing or bronchospasm. With secretions heard, suctioning is the logical first step after a quick assessment. Low-pressure alarms suggest a leak or disconnection. Alarms must never be silenced without finding the cause.
A · Assess the patient and suction if secretions are present
11.内科外科看護：神経、内分泌、腎臓
答え: D · A beta-blocker alone can cause a dangerous rise in BP
これが答えになる理由
Blocking beta receptors alone leaves catecholamines acting on alpha receptors, causing severe vasoconstriction and a hypertensive crisis. Alpha blockade, such as with phenoxybenzamine, comes first, and a beta-blocker may be added later for tachycardia.
D · A beta-blocker alone can cause a dangerous rise in BP
12.内科外科看護：神経、内分泌、腎臓
答え: B · Anticholinergic side effects of the drug
これが答えになる理由
Anticholinergic drugs such as oxybutynin can cause confusion and worsen cognition in older people. The prescriber should review the medicine and the patient's overall anticholinergic burden.
B · Anticholinergic side effects of the drug
13.内科外科看護：消化器、周術期、がん
答え: A · A metabolite can build up and cause seizures
これが答えになる理由
Pethidine's metabolite norpethidine accumulates with repeated doses or kidney impairment and can cause agitation, tremor and seizures. Other opioids are preferred.
A · A metabolite can build up and cause seizures
14.内科外科看護：消化器、周術期、がん
答え: D · Usually continue it with a sip of water, unless told otherwise
これが答えになる理由
Beta-blockers are usually continued around surgery because sudden withdrawal can cause rebound tachycardia and ischaemia. The patient follows the specific instructions from the preoperative assessment.
D · Usually continue it with a sip of water, unless told otherwise