解答つき臨床看護学ワークシート

「Sepsis Six」バンドルに含まれる項目は？

1. A血液培養を採取する
2. B退院の手配をする
3. C下剤を投与する
4. D理学療法を始める

The term "hypoxaemia" means:

1. AA low level of oxygen in the arterial blood
2. BA low level of glucose in the blood
3. CA low red blood cell count
4. DA high level of carbon dioxide in the blood

Which haemoglobin result in an adult man would be classed as anaemia?

1. A165 g/L (16.5 g/dL)
2. B140 g/L (14.0 g/dL)
3. C155 g/L (15.5 g/dL)
4. D95 g/L (9.5 g/dL)

Which pattern is typical of relapsing–remitting multiple sclerosis?

1. AAttacks of symptoms, such as visual loss or numbness, that improve between relapses
2. BA single stroke that leaves permanent weakness
3. CConstant weakness that starts in the feet and spreads upwards after a viral illness
4. DSudden severe headache with neck stiffness

Why are patients encouraged to use an incentive spirometer after abdominal surgery?

1. ATo measure their lung function so the result can go in the discharge letter
2. BTo encourage deep breaths that prevent atelectasis and chest infection
3. CTo lower their heart rate before mobilising
4. DTo strengthen the abdominal muscles around the wound

A patient is started on spironolactone while already taking an ACE inhibitor. Which blood result should be watched most closely?

1. AGlucose, because both drugs cause hyperglycaemia
2. BCalcium, because both drugs lower it
3. CSodium, because both drugs raise it sharply
4. DPotassium, because both drugs can raise it

オピオイドの PCA ポンプを使用中の患者の呼吸数が 7 回/分で、呼びかけてもなかなか起きません。まず何をすべきですか？

1. APCA を止め、患者を起こし、酸素を投与し、ナロキソンが投与されるようにする
2. B観察結果を記録し、次の 4 時間ごとの観察で再確認する
3. C痛みがあるかもしれないので PCA のボーラス量を増やす
4. D楽になるように PCA のボタンをもっと押すよう勧める

In a patient with a head injury, which is usually the earliest sign of rising intracranial pressure?

1. AA change in level of consciousness
2. BA fixed, dilated pupil on both sides
3. CA slow pulse with high blood pressure
4. DIrregular breathing pauses