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。
委任における説明責任を正しく理解している発言はどれですか？
A patient arrives at the emergency department with a plan to end their life, but has normal vital signs. Which ESI level fits best?
The laboratory calls with a critical lab result by phone. What should the nurse do?
看護師のどの行動が、手指衛生の5つのタイミングが守られていることを示していますか？
A patient without symptoms has a fasting plasma glucose of 132 mg/dL (7.3 mmol/L) on Monday and 138 mg/dL (7.7 mmol/L) on Thursday. What does this show?
A patient has eaten very little for 2 weeks and has received broad-spectrum antibiotics. The INR is now 2.3 without warfarin, and the platelets are normal. What is the most likely cause?
A patient on the ward has shingles with open blisters. Which people are most at risk from contact?
A patient with central chest pain has ST elevation on the 12-lead ECG. What is the main aim of urgent treatment?
How is the jugular venous pressure usually assessed?
A patient with squamous cell lung cancer becomes confused, thirsty and constipated, with abdominal pain. Which electrolyte disturbance is most likely?
A patient with migraine takes painkillers or triptans on most days and now has a headache almost every day. What is the likely problem?
A drowsy patient's glucose meter shows "HI". What should the nurse do?
Which is a recognised risk of long-term proton pump inhibitor use?
Why is folinic acid (leucovorin) given after high-dose methotrexate?
答え: C · 「委任するという判断と、結果のフォローアップについては、私に説明責任が残ります。」
委任した看護師は、委任するという判断と、監督および評価について説明責任を負います。委任された人は、自分の能力の範囲で業務を正しく行う責任を負います。
答え: C · Level 2
Active suicidal ideation with a plan is a high-risk situation, so the patient is ESI level 2. They need prompt evaluation and a safe environment with close observation.
答え: A · Write it down, read it back to confirm and report it to the provider promptly
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.
答え: C · ベッド柵に触れた後に手指を清潔にする
柵やテーブルなど患者の周囲環境に触れると手が汚染されるため、その後に手指衛生が必要です。手袋は患者ごとに交換し、手指衛生は手が汚れて見えるかどうかにかかわらず必要です。
答え: B · The results meet the criteria for diabetes
Two fasting results of 126 mg/dL (7.0 mmol/L) or more confirm diabetes in a person without symptoms. Prediabetes is 100–125 mg/dL. The nurse helps the patient understand the next steps, including education and follow-up.確認に用いた資料: Diabetes · MedlinePlus (NIH) (2025)
答え: B · Vitamin K deficiency
Vitamin K comes from the diet and from gut bacteria. Poor intake plus antibiotics can cause vitamin K deficiency, which lowers factors II, VII, IX and X and prolongs the PT/INR. Vitamin K replacement corrects it.確認に用いた資料: Vitamin K Deficiency in Neonates and Adults (StatPearls) · StatPearls (NCBI Bookshelf) (2026); Prothrombin time (PT) · MedlinePlus (NIH) (2025)
答え: A · Pregnant women and immunocompromised people who have not had chickenpox
Someone who has never had chickenpox can catch chickenpox from contact with shingles blisters. Non-immune pregnant and immunocompromised people are at particular risk, so lesions are covered and precautions followed.
答え: A · Restoring blood flow through the blocked coronary artery quickly
ST-elevation myocardial infarction means a coronary artery is usually completely blocked. Urgent reperfusion by primary PCI, or thrombolysis if PCI is not available in time, limits the amount of heart muscle that dies.
答え: D · Patient reclined at 45° with the head turned slightly to the left
With the patient at 45°, the vertical height of the pulsation in the right internal jugular vein above the sternal angle is estimated. A height above about 3–4 cm suggests raised right-sided pressure, as in right heart failure or fluid overload.
答え: C · Hypercalcaemia
Squamous cell lung cancer can secrete PTH-related protein, and bone metastases can release calcium. Hypercalcaemia causes confusion, thirst, polyuria, constipation, abdominal pain and arrhythmias ("bones, stones, groans and psychiatric overtones"). Treatment includes IV fluids and bisphosphonates.
答え: A · Medication overuse headache
Frequent use of painkillers or triptans can cause medication overuse headache. Treatment involves withdrawing the overused drug under guidance and starting a preventive treatment if needed.
答え: D · Treat it as very high, check ketones and escalate
"HI" means the glucose is above the meter's upper range. In a drowsy patient this may be DKA or HHS. A laboratory glucose, ketones, observations and urgent medical review are needed.
答え: B · Hypomagnesaemia
Long-term PPIs are linked with low magnesium, C. difficile infection, fractures and B12 deficiency. The need for continuing treatment should be reviewed regularly.
答え: A · To rescue normal cells from methotrexate toxicity
Methotrexate inhibits dihydrofolate reductase. Timed folinic acid bypasses this block in normal cells, reducing toxicity such as mucositis and myelosuppression, while methotrexate levels and kidney function are monitored.
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