1.やさしい
What does the Morse Fall Scale measure?
- AA patient’s skin integrity
- BA patient’s risk of falling
- CA patient’s pain level
- DA patient’s nutrition status
2.やさしい
Which statement belongs in the Background part of an SBAR report?
- A“He was admitted three days ago with pneumonia and also has COPD.”
- B“I think he may be developing sepsis.”
- C“I am calling about Mr Khan because his blood pressure has dropped.”
- D“I would like you to see him within the next 15 minutes.”
3.やさしい
Which term means being answerable for your own actions and their results?
- AAssignment
- BDelegation
- CAuthority
- DAccountability
4.ふつう
Which infant with gastroenteritis should the nurse see first?
- ALethargic, sunken fontanel, no wet diaper for 8 hours
- BTwo loose stools today, feeding well
- CAlert, crying with tears, had a wet diaper an hour ago
- DMild diaper rash, otherwise playful
5.ふつう
A nurse sees a nursing assistant leave a confused patient’s bed in the highest position after care. What should the nurse do?
- AWrite it in the assistant’s yearly review only
- BLower the bed now and remind the assistant why it matters
- CLeave it because the patient is asleep
- DAsk the family to lower the bed when they next visit
6.ふつう
A nurse gives IV morphine for severe pain. When should the nurse reassess the pain and sedation?
- AAt the next routine round in four hours
- BAt the end of the shift
- CWithin about 15–30 minutes
- DOnly when the patient asks for more
7.むずかしい
A nursing assistant has twice not reported abnormal vital signs to the RN. What is the RN’s best action?
- AStop delegating any tasks to the assistant for the rest of the year
- BComplain about the assistant to the patients during care
- CTalk to the assistant privately, restate what must be reported and follow up closely
- DSay nothing to the assistant and quietly recheck all of the assistant’s vital signs in secret
8.むずかしい
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?
- A管理者の監査の前に、看護計画を更新すること
- B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
- C敗血症が疑われる患者への、静脈内抗菌薬の初回投与
- D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
解答
- 1. B · A patient’s risk of falling
- 2. A · “He was admitted three days ago with pneumonia and also has COPD.”
- 3. D · Accountability
- 4. A · Lethargic, sunken fontanel, no wet diaper for 8 hours
- 5. B · Lower the bed now and remind the assistant why it matters
- 6. C · Within about 15–30 minutes
- 7. C · Talk to the assistant privately, restate what must be reported and follow up closely
- 8. C · 敗血症が疑われる患者への、静脈内抗菌薬の初回投与
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