解答つき優先順位の決定と委任ワークシート

Which protective equipment is needed for droplet precautions?

1. AA fitted N95 respirator at all times in the room
2. BA surgical mask when close to the patient
3. CA lead apron and goggles
4. DGloves only, with no mask

After chemotherapy, a patient has a very low neutrophil count. Which risk is the nursing priority?

1. AHypertension
2. BInfection
3. CDehydration
4. DBleeding

Which patient concern belongs to the esteem level of Maslow’s hierarchy?

1. AFear of slipping in the shower
2. BMissing friends from home
3. CThirst after a long period of fasting before a test
4. DWorry about body image after a mastectomy

A patient has a serum potassium of 2.9 mEq/L. Which finding should the nurse expect?

1. AA rise in urine output and thirst only
2. BTall, peaked T waves and muscle twitching
3. CMuscle weakness and U waves on the ECG
4. DFlushed, warm skin and a slow heart rate

A nurse needs to give report on a patient to a colleague. Which information is the most important to include?

1. AThe patient’s current condition, recent changes and pending tasks
2. BDetails of the nurse’s own break times that shift
3. CThe patient’s favorite television programs and hobbies
4. DPersonal opinions about the patient’s family members and their visiting habits

A parent of a child with influenza talks with the nurse. Which statement shows a need for further teaching?

1. A“I will give my child plenty of fluids.”
2. B“I will give my child aspirin to bring the fever down.”
3. C“I will call if my child has trouble breathing.”
4. D“I will keep my child home from school and away from others while unwell.”

心不全の患者が息切れを起こし、両肺に湿性ラ音があります。正しい行動の順序はどれですか？

1. A座位にし、処方に従って酸素を投与し、そのあと医療者に連絡する
2. B休ませるために平らに寝かせ、そのあと維持輸液を開始する
3. C定時の経口薬を先に投与し、そのあと座位にする
4. D先に体重を測定し、そのあと 4 時間後に呼吸を再評価する

看護助手が、患者のモルヒネの初回投与の 15 分後にバイタルサインを測定しました。呼吸数は 10 回/分で、患者は起こしにくいと報告します。看護師はどうすべきですか？

1. A15 分後に呼吸数を再測定して報告するよう、助手に頼む
2. B患者を診に行く前に、医療者に電話して指示をもらう
3. Cすぐに行き、患者を覚醒させ、呼吸を補助し、指示に従ってナロキソンを準備する
4. D所見を記録し、次の定時ラウンドで医療者に伝える