An older patient has bruises of different ages and seems frightened when a relative visits. What is the nurse’s priority?
AIgnore it, because older people bruise easily
BEnsure the patient’s safety, document the findings and report as required
CTell the patient she must leave home and go to live somewhere else
DAsk the relative directly in front of the patient whether they hit her
15.感染管理と患者の安全ふつう
A patient with delirium is at risk of falls and of pulling out lines. Which option is less restrictive than restraints?
AA vest restraint applied for the whole night
BA trained sitter or video monitoring with staff nearby
CA sedative given every few hours as needed
DFour side rails raised and the door closed so the patient stays in bed
16.感染管理と患者の安全むずかしい
A nurse who is not immune to chickenpox was exposed to a patient with varicella before precautions began. What usually happens?
AThe nurse is assessed and kept from patient contact during the incubation period per policy
BThe nurse must take a two-week course of antibiotics to prevent the infection
CThe nurse only needs to wear gloves for the next month
DThe nurse continues working with all patients as usual, including newborns
17.検査値と電解質ふつう
高カルシウム血症に合致する所見の組み合わせはどれですか?
A便秘、疲労、錯乱、腎結石
Bテタニー、筋肉のこむら返り、陽性のクボステック徴候
C唯一のサインとしての、非常に薄い尿を伴う口渇
D尖った T 波と筋力低下のみ
18.検査値と電解質むずかしい
A patient on digoxin has a calcium of 12.1 mg/dL (3.0 mmol/L) and new nausea and a slow pulse. Why is the calcium result important?
AHigh calcium makes the kidneys clear digoxin faster
BHigh calcium only matters if the potassium is also high
CHigh calcium blocks digoxin, so the drug stops working
DHigh calcium increases the risk of digoxin toxicity
3溶液
1.基礎看護学
答え: B · 無菌操作
これが答えになる理由
尿道カテーテルは、カテーテル関連尿路感染を減らすため、無菌操作と滅菌物品で挿入します。
答え
B · 無菌操作
2.基礎看護学
答え: A · Give a longer-acting carbohydrate, such as a sandwich
これが答えになる理由
Fast-acting glucose raises the level quickly but briefly. A starchy snack, or the next meal if due, keeps it from falling again. The episode is recorded and its cause reviewed.
答え
A · Give a longer-acting carbohydrate, such as a sandwich
3.臨床看護学
答え: D · Constipation
これが答えになる理由
Opioids slow gut movement, and constipation persists with long-term use. A regular laxative is usually prescribed together with the opioid.
答え
D · Constipation
4.臨床看護学
答え: A · The letters can be misread as a zero, causing a tenfold overdose
これが答えになる理由
"U" can be misread as 0, so "10U" might be read as 100, and "IU" can be mistaken for "IV" or "10". Writing "units" in full is a standard safety rule (ISMP), because insulin errors can cause severe hypoglycaemia.
答え
A · The letters can be misread as a zero, causing a tenfold overdose
2:1 房室ブロック:QRS 1 つに P 波が 2 つあるとき、伝導した P 波が連続しないので、伝導されなかった P 波の前で PR が延びるか(I 型)、一定か(II 型)を判断できません。1 枚の波形からは 2:1 房室ブロックと呼びます。型は、より長い波形や伝導比の変化で決まります。QRS の幅が狭ければ I 型の可能性が高く、広ければ II 型の可能性が高いのですが、どちらも決め手にはなりません。
5つのステップ
1. 心拍数:R–R = 小さいマス目 38 個、1500 ÷ 38 ≈ 39 回/分。
2. リズム:整。すべての R–R は 1.52 秒です。
3. P波:陽性で整(P–P 0.76 秒、79 回/分)。QRS 1つにつき2個あります。
4. PR 間隔:伝導された拍では 0.18 秒で一定です。
5. QRS:0.06 秒で幅が狭い(0.12 秒未満)。
型が決まらない理由
2 つに 1 つの P 波が伝導されないので、伝導した拍動が連続せず、PR の延長を確認できません。
2:1 房室ブロック(型は特定不能)
答え
2:1 房室ブロック(型は特定不能)
QRS の幅が狭ければ I 型の可能性が高く、広ければ II 型の可能性が高いのですが、決め手になるのは、より長い波形か伝導比の変化だけです。
13.優先順位の決定と委任
答え: B · 「10 時にリーさんの血圧を測って、収縮期血圧が 100 未満なら、すぐに知らせてください。」
B · 「10 時にリーさんの血圧を測って、収縮期血圧が 100 未満なら、すぐに知らせてください。」
14.優先順位の決定と委任
答え: B · Ensure the patient’s safety, document the findings and report as required
これが答えになる理由
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
B · Ensure the patient’s safety, document the findings and report as required
15.感染管理と患者の安全
答え: B · A trained sitter or video monitoring with staff nearby
これが答えになる理由
Close observation by a sitter or video monitoring allows staff to step in quickly, without restricting the patient. It is often combined with reorientation and family presence.
答え
B · A trained sitter or video monitoring with staff nearby
16.感染管理と患者の安全
答え: A · The nurse is assessed and kept from patient contact during the incubation period per policy
これが答えになる理由
A non-immune worker exposed to varicella may become infectious before the rash appears, so they are usually excluded from patient contact for the incubation period, and post-exposure vaccination or other measures may be offered.
答え
A · The nurse is assessed and kept from patient contact during the incubation period per policy
17.検査値と電解質
答え: A · 便秘、疲労、錯乱、腎結石
これが答えになる理由
高カルシウムは神経と筋の興奮性を低下させ、疲労、便秘、錯乱、骨の痛み、腎結石を起こします。テタニーとクボステック徴候は、低カルシウムのサインです。確認に用いた資料:Calcium Blood Test · MedlinePlus (NIH) (2024)
答え
A · 便秘、疲労、錯乱、腎結石
18.検査値と電解質
答え: D · High calcium increases the risk of digoxin toxicity
これが答えになる理由
Hypercalcemia, like hypokalemia and hypomagnesemia, makes the heart more sensitive to digoxin and raises the risk of toxic arrhythmias. Nausea and bradycardia suggest toxicity, so the nurse holds the dose and reports the findings.
答え
D · High calcium increases the risk of digoxin toxicity