解答つき優先順位の決定と委任ワークシート

An adult arrives at the emergency department with chest pain. Which test should be done within about 10 minutes of arrival?

1. AA chest CT scan
2. BAn exercise stress test
3. CA lipid profile
4. DA 12-lead ECG

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

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

アセスメント、看護の判断、評価を必要とする業務は、どうすべきですか？

1. A常に LPN/LVN に委任する
2. B患者の家族に任せる
3. C最も経験豊富な看護助手に委任する
4. D看護師（RN）が行う

A patient with schizophrenia says voices are telling him to hurt his roommate. What is the priority?

1. AIgnore the comment, because voices are part of his illness
2. BAsk the roommate to stay in the room with him and help calm him down
3. CKeep everyone safe and tell the team, as the risk of harm is high
4. DTell him the voices are not real and leave him alone

Which patient is most suitable for the nurse to assign to a nurse who has just finished orientation?

1. AA patient with a new tracheostomy who needs frequent suctioning
2. BA patient with stable cellulitis on scheduled IV antibiotics
3. CA patient on a continuous heparin infusion with rising aPTT values
4. DA patient with sepsis whose blood pressure is falling

A patient arrives in the recovery room after general anesthesia. What does the nurse assess first?

1. AUrine output
2. BThe surgical dressing and the drains
3. CThe pain score
4. DAirway patency and breathing

A patient with severe sepsis starts oozing blood from IV sites and the gums, and bruises appear on the skin. What should the nurse suspect?

1. AVitamin C deficiency
2. BNormal bruising from blood tests
3. CAn allergic reaction to the adhesive tape
4. DDisseminated intravascular coagulation (DIC)

A chemical cleaning fluid splashes into a patient’s eye. What should the nurse do first?

1. ACover the eye with a dry patch and wait for the provider
2. BFlush the eye with plenty of water or saline straight away
3. CGive antibiotic eye drops first
4. DRub the eye gently with a clean tissue to remove the chemical