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

Several patients on a gastroenterology unit need care. Which patient should the nurse see first?

  1. ACrohn disease, waiting to be taken down for a scheduled CT scan
  2. BUlcerative colitis, asking about diet changes for home
  3. CLong-standing back pain, asking for the usual analgesic
  4. DTwo hours after a colonoscopy: rigid abdomen and severe new pain
2.優先順位の決定と委任むずかしい

An older adult with type 2 diabetes is confused and very dehydrated. The glucose is 900 mg/dL (50 mmol/L), and blood and urine show no significant ketones. What is the most likely problem?

  1. ADiabetic ketoacidosis
  2. BStress-induced mild hyperglycemia
  3. CHypoglycemia with rebound
  4. DHyperosmolar hyperglycemic state
3.感染管理と患者の安全ふつう

A patient needs to be moved up in bed and cannot help much. Which approach is safest?

  1. AHave one nurse pull the patient up by the arms
  2. BAsk the patient to push up with their heels alone
  3. CRaise the head of the bed fully and lift the patient up by the shoulders
  4. DUse a friction-reducing sheet with enough staff, with the bed flat if tolerated
4.感染管理と患者の安全むずかしい

A patient’s WBC is 4,000/mm3, with 30% neutrophils and 5% bands. What is the absolute neutrophil count (ANC)?

  1. A1,400/mm3
  2. B3,500/mm3
  3. C140/mm3
  4. D1,200/mm3
5.検査値と電解質ふつう

A patient with a low clinical probability of deep vein thrombosis has a normal (negative) D-dimer. What is the best interpretation?

  1. AA DVT is confirmed and anticoagulation is needed
  2. BThe test is useless and should always be ignored
  3. CA DVT is unlikely and can usually be ruled out
  4. DA pulmonary embolism is now certain to be present
6.検査値と電解質むずかしい

A patient on a stable dose of levothyroxine now has a TSH of 9.8 mIU/L. She recently started taking her calcium and iron supplements with her morning levothyroxine. What is the most likely explanation?

  1. AThe result is normal for a person on levothyroxine therapy
  2. BThe supplements are causing an overactive thyroid gland
  3. CThe supplements are reducing levothyroxine absorption
  4. DThe TSH is low, showing that the dose is now too high
7.臨床看護学ふつう

How does CPAP help a patient with obstructive sleep apnoea?

  1. AIt strengthens the breathing muscles during the day
  2. BIt delivers bronchodilator drugs deep into the lungs overnight
  3. CIt removes excess carbon dioxide from the lungs by gentle suction
  4. DIt keeps the upper airway open during sleep with continuous air pressure
8.臨床看護学むずかしい

A patient has a painful, punched-out ulcer on the toes, with a cold, pale foot and weak foot pulses. Which type of ulcer is most likely?

  1. AA venous ulcer
  2. BA burn
  3. CAn arterial ulcer
  4. DA pressure ulcer from bed rest
9.内科外科看護：循環器と呼吸器ふつう

Which emergency equipment should be kept at the bedside of a patient with a tracheostomy?

  1. ASpare tubes (same size and one smaller), suction and oxygen
  2. BA urinary catheter set, a blood glucose meter and a thermometer
  3. COnly a spare oxygen mask, since the tube rarely causes problems
  4. DA nasogastric tube and a feeding pump
10.内科外科看護：循環器と呼吸器むずかしい

A patient with a stab wound to the chest has a hole that sucks air with each breath. What is the immediate management?

  1. ACover it with a vented chest seal or a dressing taped on three sides
  2. BLeave it open and give a nebuliser
  3. CSeal it completely with tape on all four sides and leave it alone
  4. DPack the wound tightly with gauze pushed deep into the chest
11.内科外科看護：神経、内分泌、腎臓ふつう

A patient with Conn's syndrome starts spironolactone. Which blood test should the nurse watch most closely?

  1. ACalcium
  2. BAmylase
  3. CGlucose
  4. DPotassium
12.内科外科看護：神経、内分泌、腎臓むずかしい

A patient in thyroid storm has a temperature of 40 °C (104 °F). Which measure for the fever is usually avoided?

  1. AParacetamol (acetaminophen)
  2. BAspirin
  3. CFanning with cool air
  4. DCooling blankets
13.内科外科看護：消化器、周術期、がんふつう

Which intervention most reduces pressure ulcer risk in an immobile patient?

  1. AKeeping the head of the bed raised at 90° all day
  2. BRegular repositioning and a pressure-redistributing mattress
  3. CMassaging red areas firmly at each turn to bring back the circulation
  4. DUsing a doughnut-shaped ring cushion
14.内科外科看護：消化器、周術期、がんむずかしい

During radiotherapy to the chest, a patient develops pain on swallowing and is eating less. What is the most likely cause and nursing focus?

  1. ARadiation oesophagitis; analgesia, soft food and nutrition support
  2. BA stomach ulcer; give an antacid after meals only
  3. CNormal ageing; no action needed
  4. DA heart attack; give aspirin and arrange an ECG

3溶液

1.優先順位の決定と委任

答え: D · Two hours after a colonoscopy: rigid abdomen and severe new pain

これが答えになる理由

A rigid abdomen with severe pain after colonoscopy suggests bowel perforation and peritonitis, a surgical emergency. The other patients have stable, chronic or routine needs.

答え

D · Two hours after a colonoscopy: rigid abdomen and severe new pain
2.優先順位の決定と委任

答え: D · Hyperosmolar hyperglycemic state

これが答えになる理由

Hyperosmolar hyperglycemic state occurs mainly in type 2 diabetes, with extreme glucose, severe dehydration and little or no ketosis. Treatment starts with IV fluids, as in DKA.

答え

D · Hyperosmolar hyperglycemic state
3.感染管理と患者の安全

答え: D · Use a friction-reducing sheet with enough staff, with the bed flat if tolerated

これが答えになる理由

Lowering the head of the bed, if the patient tolerates it, and using a slide sheet with two or more staff reduces the force needed. Pulling on arms can injure shoulders, and dragging damages skin.

答え

D · Use a friction-reducing sheet with enough staff, with the bed flat if tolerated
4.感染管理と患者の安全

答え: A · 1,400/mm3

これが答えになる理由

ANC = 4,000 × (0.30 + 0.05) = 1,400/mm3. This is below normal (neutropenia), so the patient has a raised risk of infection.

答え

A · 1,400/mm3
5.検査値と電解質

答え: C · A DVT is unlikely and can usually be ruled out

これが答えになる理由

D-dimer is very sensitive, so a negative result in a patient with low clinical probability makes DVT or PE unlikely. A positive result is not specific, because surgery, infection, pregnancy and cancer also raise D-dimer; imaging is then needed.確認に用いた資料: D-Dimer Test · MedlinePlus (NIH) (2024)

答え

C · A DVT is unlikely and can usually be ruled out
6.検査値と電解質

答え: C · The supplements are reducing levothyroxine absorption

これが答えになる理由

Calcium, iron and antacids bind levothyroxine in the gut and reduce absorption, so the TSH rises. Levothyroxine is taken on an empty stomach, usually 30–60 minutes before breakfast, separated from these supplements by about 4 hours.

答え

C · The supplements are reducing levothyroxine absorption
7.臨床看護学

答え: D · It keeps the upper airway open during sleep with continuous air pressure

これが答えになる理由

Continuous positive airway pressure acts as a splint for the upper airway, preventing collapse and apnoeas. Patients should bring their CPAP machine into hospital.

答え

D · It keeps the upper airway open during sleep with continuous air pressure
8.臨床看護学

答え: C · An arterial ulcer

これが答えになる理由

Arterial ulcers are usually on the feet or toes, painful and punched-out, with signs of poor perfusion. Venous ulcers are usually around the ankle, shallow and associated with swelling and skin staining.

答え

C · An arterial ulcer
9.内科外科看護：循環器と呼吸器

答え: A · Spare tubes (same size and one smaller), suction and oxygen

これが答えになる理由

Bedside equipment usually includes spare tracheostomy tubes (same size and one size smaller), an obturator if used, suction with catheters, oxygen, a bag-valve-mask and tracheal dilators where policy requires. It is checked at every shift.

答え

A · Spare tubes (same size and one smaller), suction and oxygen
10.内科外科看護：循環器と呼吸器

答え: A · Cover it with a vented chest seal or a dressing taped on three sides

これが答えになる理由

An open (sucking) chest wound lets air enter the pleural space. A vented chest seal or a dressing taped on three sides acts as a flap valve, letting air out but not in. A fully sealed dressing can cause a tension pneumothorax. A chest drain is placed away from the wound.

答え

A · Cover it with a vented chest seal or a dressing taped on three sides
11.内科外科看護：神経、内分泌、腎臓

答え: D · Potassium

これが答えになる理由

Spironolactone is an aldosterone antagonist. It retains potassium, so hyperkalaemia can develop, especially with kidney disease or ACE inhibitors. Breast enlargement is another known side effect.

答え

D · Potassium
12.内科外科看護：神経、内分泌、腎臓

答え: B · Aspirin

これが答えになる理由

Aspirin (salicylates) displaces thyroid hormone from binding proteins, raising free hormone levels. Paracetamol (acetaminophen) and external cooling are used instead, together with treatment for the storm itself.

答え

B · Aspirin
13.内科外科看護：消化器、周術期、がん

答え: B · Regular repositioning and a pressure-redistributing mattress

これが答えになる理由

Regular repositioning according to risk and suitable support surfaces reduce pressure. Massaging red areas and ring cushions can damage tissue and are not recommended.

答え

B · Regular repositioning and a pressure-redistributing mattress
14.内科外科看護：消化器、周術期、がん

答え: A · Radiation oesophagitis; analgesia, soft food and nutrition support

これが答えになる理由

Radiotherapy to the chest can inflame the oesophagus, causing painful swallowing. Analgesia (sometimes before meals), soft moist food, nutritional supplements, dietitian input and monitoring weight are important.

答え

A · Radiation oesophagitis; analgesia, soft food and nutrition support

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