解答つき優先順位の決定と委任ワークシート

In mass-casualty triage, what does a yellow tag usually mean?

1. ADelayed: serious injuries, but care can safely wait a little
2. BDeceased or not expected to survive
3. CImmediate: life-threatening injuries that are survivable with quick care
4. DMinor: the walking wounded

3 段階のトリアージ分類で、「緊急」にあたる患者はどれですか？

1. A処方の再発行の依頼
2. B発汗と息切れを伴う胸痛
3. C発熱のない、3 日間の発疹
4. Dバイタルサインが正常な、2 日間の腹痛

Using the rule of nines, what percentage of body surface does one whole arm represent in an adult?

1. A9%
2. B36%
3. C1%
4. D18%

Which postoperative patient should the nurse see first?

1. ADressing soaked with bright red blood and a heart rate rising to 118/min
2. BWants help with washing her hair before her visitors arrive this afternoon
3. CAsking when the urinary catheter will be removed
4. DPain of 4/10 one hour after an oral analgesic

甲状腺の手術の 4 時間後、看護師が最初に対応すべき患者の所見はどれですか？

1. A切開部の痛みが 4/10
2. B飲むために座りたいという要望
3. C声がしだいにかすれ、新たにぜいぜいした呼吸がある
4. D頸部のドレッシングに少量の漿液性の排液がみられる

Which patient is at the highest risk of falling?

1. AA 45-year-old with asthma who is alert and independent
2. BA 30-year-old after an appendectomy who walks with steady steps
3. CAn 84-year-old taking a diuretic who has fallen before and gets up at night
4. DA 60-year-old admitted for chest pain that has since been ruled out by tests

A child is admitted with a suspected Wilms tumor (nephroblastoma). Which instruction is most important for all staff?

1. AGive a warm bath with abdominal massage
2. BEncourage the child to play contact sports
3. CDo not palpate the abdomen
4. DMeasure abdominal girth by pressing firmly

A patient in acute mania paces constantly, has lost weight and will not sit down to eat. Which intervention is most helpful?

1. AInsist that the patient sits at the table until the meal is finished
2. BOffer high-calorie finger foods and drinks the patient can take while moving
3. CLeave meals in the room and let the patient eat whenever and whatever they choose
4. DWait until the mania settles before worrying about nutrition