解答つき基礎看護学ワークシート

看護過程の最初のステップは何ですか？

1. A評価
2. Bアセスメント
3. C実施
4. D計画

What does a healthy stoma usually look like?

1. ADark purple or black
2. BMoist and pink to red
3. CDry and covered in a crust
4. DDry and pale white

Which part of a sterile field is considered not sterile?

1. AThe outer 2.5 cm (1 inch) border
2. BItems placed in the middle of the field
3. CThe centre of the field
4. DThe area just in front of the nurse

A goal states: "The patient will report pain of 3/10 or less within one hour of analgesia." After one hour the patient reports 6/10. What should the nurse do?

1. ARecord the goal as met, as the pain has gone down
2. BChange the goal to 6/10 or less so that it counts as met
3. CRecord the goal as not met and review the plan
4. DWait until the next day to evaluate again

While being helped to eat, a patient with dysphagia coughs and their voice sounds wet and gurgly. What should the nurse do?

1. AGive a drink of water to wash the food down
2. BLie the patient flat to rest
3. CStop feeding and report for a swallowing assessment
4. DFeed more quickly so the meal is finished before they tire

What is the purpose of a negative-pressure isolation room?

1. AAir flows into the room, so airborne particles do not escape into the corridor
2. BIt makes it easier for patients to breathe
3. CAir flows out of the room, keeping germs from the corridor away from the patient
4. DThe low pressure kills bacteria inside the room

A collapsed patient is unresponsive and making only occasional slow gasps. What should the nurse do?

1. APlace the patient in the recovery position and keep observing them
2. BGive a sip of water to clear the throat
3. CWait to see whether the gasps become regular
4. DTreat it as not breathing normally, call for help and start CPR

A patient taking furosemide has a serum potassium of 3.0 mmol/L (3.0 mEq/L). Why is this important?

1. AFurosemide raises potassium, so this level is falsely low and can be ignored
2. BThe level is normal and needs no action
3. CLoop diuretics cause potassium loss, and low levels can cause arrhythmias
4. DLow potassium only causes mild thirst