解答つき内科外科看護：消化器、周術期、がんワークシート

What is the Braden scale (or a similar tool such as Waterlow) used for?

1. AMeasuring a patient's level of consciousness
2. BAssessing the risk of developing pressure ulcers
3. CGrading the depth of a burn wound before dressing it
4. DScoring the severity of nausea

Why is nail varnish or a gel nail often removed from at least one finger before surgery?

1. ASo pulse oximetry readings and nail colour can be assessed accurately
2. BBecause it is a checklist rule with no clinical reason
3. CBecause the varnish can make the anaesthetic gas less effective
4. DBecause varnish raises the patient's blood pressure

Which feature is typical of an arterial leg ulcer?

1. AA painful, punched-out wound on a cold, pale foot
2. BA shallow, wet wound around the ankle with warm, swollen skin
3. CA painless wound on the shin with normal pulses
4. DA blister on the heel with plenty of hair growth

Which liver function test pattern suggests bile duct obstruction?

1. AHigh bilirubin with a markedly raised ALP and GGT
2. BVery high ALT with a normal bilirubin only
3. CNormal bilirubin with a low ALP and low GGT
4. DA low albumin with all other results normal

Aspirate from a nasogastric tube has a pH of 7. What should the nurse do?

1. AGive the medicines but not the feed
2. BDo not use it; re-test later or arrange an X-ray as per policy
3. CFlush with 50 mL of air and start the feed
4. DStart the feed slowly and watch the patient closely for coughing

A dying patient can no longer drink. Which mouth care is most appropriate?

1. ALemon and glycerine swabs every hour to stimulate saliva
2. BBrushing hard with a stiff toothbrush twice a day
3. CNo mouth care, to avoid disturbing the patient
4. DFrequent, gentle moistening of the mouth and lips

化学療法の後にフィルグラスチム（G-CSF）を使っている患者が、予想される副作用は何かと尋ねました。最も多い副作用はどれですか？

1. A白血球数の急速な低下
2. B初回の注射から数日以内の、完全な脱毛
3. C恒久的な難聴
4. D骨髄が刺激されることによる、うずくような骨の痛み

A sacral wound has heavy exudate, and the surrounding skin is white, soft and wrinkled. What should the nurse do?

1. AUse a dressing that adds even more moisture
2. BApply a tight plastic film directly over the wound
3. CLeave the same dressing in place for a week so the wound is not disturbed
4. DProtect the skin edges and use a more absorbent dressing