A patient arrives in the recovery room after general anesthesia. What does the nurse assess first?
AAirway patency and breathing
BThe surgical dressing and the drains
CUrine output
DThe pain score
14.優先順位の決定と委任むずかしい
A patient at 36 weeks of pregnancy has sudden severe abdominal pain, a hard, board-like uterus and dark vaginal bleeding. What should the nurse suspect?
AA urinary tract infection
BPlacental abruption, which is an emergency
CPlacenta previa, which is usually painless
DNormal labor contractions starting
15.感染管理と患者の安全ふつう
A nurse gives part of a dose of an opioid from a vial and must discard the rest. What is correct?
ADiscard it in front of a second licensed (registered) nurse, who witnesses and documents it
BDiscard it alone in the sink and document the amount wasted later in the shift
CReturn the rest to the patient’s medication drawer
DKeep the rest for the patient’s next dose
16.感染管理と患者の安全むずかしい
Minutes after the first IV dose of an antibiotic starts, the patient develops wheezing, hives and low blood pressure. What should the nurse do first?
ARecord the new allergy in the chart
BStop the infusion
CGive an oral antihistamine
DSlow the infusion rate
17.検査値と電解質ふつう
A nurse has a needlestick injury from a patient with unknown HIV status. Which test is usually done for the nurse as soon as possible?
AA sweat chloride test
BA thyroid panel test
CA baseline HIV test
DA serum lipase test
18.検査値と電解質むずかしい
A patient using an insulin pump has a glucose of 300 mg/dL (16.7 mmol/L) that has not fallen 2 hours after a correction bolus through the pump. Blood ketones are 1.8 mmol/L. What is the most likely problem and action?
AInsulin overdose from the pump; suspend the pump and stop all insulin for a day
BNormal pump function; wait for the next mealtime bolus to lower the glucose
CRebound after a hypo; give fast-acting carbohydrate and recheck in 15 minutes
DInsulin delivery failure; inject a correction dose by pen and change the set
3溶液
1.基礎看護学
答え: C · No more than about 10–15 seconds
これが答えになる理由
Suction removes oxygen as well as secretions. Keeping passes short, oxygenating as needed and watching SpO₂ reduces hypoxia and airway trauma.
After anesthesia, the airway can be blocked by the tongue or secretions, and breathing may be depressed. The airway and breathing are checked first, followed by circulation and the wound.
答え
A · Airway patency and breathing
14.優先順位の決定と委任
答え: B · Placental abruption, which is an emergency
これが答えになる理由
Painful bleeding with a rigid, tender uterus suggests placental abruption, where the placenta separates early. Mother and baby are at risk, so urgent escalation and monitoring are needed.
答え
B · Placental abruption, which is an emergency
15.感染管理と患者の安全
答え: A · Discard it in front of a second licensed (registered) nurse, who witnesses and documents it
これが答えになる理由
Wasting controlled substances requires a witness, usually another licensed nurse, and both document the waste. This prevents and detects drug diversion.
答え
A · Discard it in front of a second licensed (registered) nurse, who witnesses and documents it
16.感染管理と患者の安全
答え: B · Stop the infusion
これが答えになる理由
These are signs of anaphylaxis. The nurse stops the infusion at once, calls for help and supports the airway, and intramuscular epinephrine (adrenaline) is the first-line treatment. Documentation comes later.
答え
B · Stop the infusion
17.検査値と電解質
答え: C · A baseline HIV test
これが答えになる理由
After an occupational exposure, the wound is washed and the incident is reported at once. Baseline tests for HIV, hepatitis B and hepatitis C are taken, and post-exposure prophylaxis is started as soon as possible if indicated, ideally within hours.
答え
C · A baseline HIV test
18.検査値と電解質
答え: D · Insulin delivery failure; inject a correction dose by pen and change the set
これが答えになる理由
A high glucose that does not respond to a pump bolus, with rising ketones, suggests a kinked, blocked or dislodged cannula. Because pumps use only rapid-acting insulin, DKA can develop within hours. The usual advice is to give a correction dose by pen or syringe, change the infusion set, check glucose and ketones often, and seek help if ketones keep rising or vomiting starts.
答え
D · Insulin delivery failure; inject a correction dose by pen and change the set