解答つき優先順位の決定と委任ワークシート

看護の優先順位を決める ABC の枠組みでは、どのニーズが最初に対処されますか？

1. A循環（Circulation）
2. B気道（Airway）
3. C呼吸（Breathing）
4. D痛み

What is the normal baseline fetal heart rate?

1. A40–60/min
2. B110–160/min
3. C60–100/min
4. D160–220/min

When is a patient most ready to learn about self-care?

1. ADuring a period of acute breathlessness
2. BStraight after hearing bad news about a serious new diagnosis
3. CWhen pain is controlled and basic physical needs are met
4. DWhile in severe pain, so the lesson feels important

During an IV vancomycin infusion, a patient develops flushing and itching of the face and neck. What should the nurse do first?

1. AIgnore it, because flushing is always harmless and passes
2. BStop or slow the infusion and inform the provider
3. CSpeed up the infusion to finish it quickly
4. DApply a warm compress to the face and neck

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

1. AKeeping the drainage bag below the level of the bladder
2. BRaising the drainage bag above the bladder when walking
3. CLeaving the catheter in place longer than needed
4. DDisconnecting the bag every shift to empty it

A patient with mild dysphagia after a stroke is eating. Which technique helps make swallowing safer?

1. ATalking while eating to stay alert
2. BDrinking thin fluids quickly through a straw between bites
3. CLying flat with the head tilted back
4. DSitting upright with the chin tucked down while swallowing

上部消化管出血の患者の心拍数が 128 回/分、血圧が 84/50 mmHg です。以下はすべて処方されています。看護師が最初に開始するのはどれですか？

1. A診断のための内視鏡検査を翌朝に予約すること
2. Bプロトンポンプ阻害薬の静脈内点滴
3. C太い静脈留置針による輸液または輸血
4. D経口の鉄剤

During JumpSTART triage, a child who cannot walk is breathing 50 times a minute. Which category is the child given?

1. AYellow (delayed)
2. BRed (immediate)
3. CGreen (minor)
4. DBlack (expectant)