解答つき臨床看護学ワークシート

How should nursing records be written?

1. AIn pencil so that mistakes can be rubbed out
2. BAccurately and as soon as possible after the event, with date, time and signature
3. CAt the end of the week, written from memory in one go to save time
4. DUsing personal abbreviations that only the nurse who wrote them understands

What does "cyanosis" describe?

1. AA yellow colour of the skin and eyes caused by raised bilirubin
2. BA red, flushed face from fever
3. CPale skin caused by fear or pain
4. DA bluish colour of the skin or lips from poorly oxygenated blood

オピオイド鎮痛薬を使っている患者で特に観察すべきことは？

1. A下痢
2. B高血圧
3. C呼吸抑制と鎮静
4. D食欲の増加

Which type of painkiller should a patient with liver cirrhosis usually avoid?

1. ANon-steroidal anti-inflammatory drugs such as ibuprofen
2. BHot packs applied to a painful joint
3. CParacetamol (acetaminophen), given in a carefully reduced and monitored dose
4. DLocal anaesthetic creams

患者に疝痛性の腹痛、腹部膨満、嘔吐があり、2 日間排便も排ガスもありません。考えられる問題は？

1. A腸閉塞
2. B過敏性腸症候群
3. C胃腸炎
4. D合併症のない虫垂炎

Why is blood pressure monitored closely in a patient with an epidural infusion?

1. ABlood pressure readings show whether the catheter is infected
2. BThe local anaesthetic can block sympathetic nerves and cause hypotension
3. CThe epidural pump uses the blood pressure to set the rate
4. DEpidurals always cause severe hypertension that needs regular treatment

During a blood transfusion, an older patient with heart failure becomes breathless with a rising blood pressure, raised JVP and crackles in the lungs. What is the most likely cause?

1. AA febrile non-haemolytic reaction
2. BAnaphylaxis
3. CTransfusion-associated circulatory overload
4. DTransfusion-related acute lung injury with hypotension

急性消化管出血の患者の心拍数は 120 回/分、血圧は 90/60 mmHg です。助けを呼んだ後の看護の優先事項は？

1. Aひとりでトイレまで歩くよう勧める
2. B太い留置針で静脈路を確保し、輸液や輸血の準備をする
3. C便の色を確認するまで対応を遅らせる
4. Dエネルギーを回復させるために十分な食事を与える