解答つき優先順位の決定と委任ワークシート

A patient has a Glasgow Coma Scale score of 8. What is the main concern?

1. AThe patient can safely eat and drink without help
2. BThe patient is fully alert and oriented
3. CThe patient only has a mild headache
4. DThe patient may not be able to protect the airway

After caring for a patient with Clostridioides difficile diarrhea, how should the nurse clean their hands?

1. AWash with soap and water
2. BWipe hands on a clean towel
3. CUse alcohol hand rub only
4. DNo hand hygiene is needed if gloves were worn

Why may a full-thickness burn feel painless at its center?

1. AThe nerve endings in the skin have been destroyed
2. BThe burn has already fully healed
3. CThe burn only affects the thin surface layer of the skin
4. DThe patient has been given too much fluid

A nurse has given rapid-acting insulin, and then learns that the patient’s meal tray will be 45 minutes late. What should the nurse do?

1. AAsk the patient to walk around the ward until the food arrives
2. BGet the patient some carbohydrate food now and check the glucose
3. CGive a second, smaller dose of insulin when the meal tray finally arrives
4. DTell the patient to wait and do nothing until the tray comes

Which action helps prevent a catheter-associated urinary tract infection?

1. ADisconnecting the bag every shift to empty it
2. BKeeping the drainage bag below the level of the bladder
3. CRaising the drainage bag above the bladder when walking
4. DLeaving the catheter in place longer than needed

Several patients on a gastroenterology unit need care. Which patient should the nurse see first?

1. ALong-standing back pain, asking for the usual analgesic
2. BCrohn disease, waiting to be taken down for a scheduled CT scan
3. CUlcerative colitis, asking about diet changes for home
4. DTwo hours after a colonoscopy: rigid abdomen and severe new pain

看護師が最初に対応すべき看護助手の報告はどれですか？

1. A糖尿病の患者が、いつもどおり足がよくピリピリすると言う
2. B今朝の腰椎固定術の後、脚の感覚がなく動かせない
3. C肺炎の患者が黄色い痰を出した
4. D安静臥床の患者が、便器を求めている

忙しい勤務中に、4 つの業務が予定されています。看護師が最初に行うべきなのはどれですか？

1. A敗血症が疑われる患者への、静脈内抗菌薬の初回投与
2. B同じ時刻に予定されている、毎日のビタミン錠の定時投与
3. C管理者の監査の前に、看護計画を更新すること
4. D安定した患者が明日のメニューカードを記入するのを手伝うこと