解答つき優先順位の決定と委任ワークシート

Which finding is one of the quick SOFA (qSOFA) criteria for possible sepsis?

1. ARespiratory rate of 22/min or more
2. BBlood glucose above 100 mg/dL
3. CHeart rate below 60/min
4. DTemperature below 36.5 °C on one reading

A patient’s urine output is 15 mL/h for three hours. How should the nurse classify this in an adult?

1. AHigh, suggesting fluid overload
2. BExpected after drinking fluids
3. CLow and needing to be reported
4. DNormal for an adult at rest

Which maneuver opens the airway of an unresponsive adult with no suspected spinal injury?

1. ARaising the legs above the heart
2. BHead-tilt, chin-lift
3. CJaw thrust without head tilt
4. DTurning the head sharply to one side

The day after a total thyroidectomy, a patient reports tingling around the mouth and in the fingers. What should the nurse do first?

1. AReassure the patient that this is normal after neck surgery
2. BCheck for signs of low calcium and inform the provider
3. CEncourage deep breaths into a paper bag until it passes
4. DGive the patient’s routine oral iron supplement early

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 on a continuous heparin infusion with rising aPTT values
3. CA patient with stable cellulitis on scheduled IV antibiotics
4. DA patient with sepsis whose blood pressure is falling

A patient has taken prednisone (prednisolone in many countries) for several months. Which statement shows a need for further teaching?

1. A“I will report signs of infection early.”
2. B“I will stop the tablets as soon as I feel better.”
3. C“I will take the tablets with food.”
4. D“I will tell my dentist and other doctors that I take a steroid.”

A patient in labor is receiving oxytocin, and the fetal monitor shows repeated late decelerations. What should the nurse do first?

1. AStop the oxytocin infusion
2. BIncrease the oxytocin rate
3. CPlace the patient flat on her back
4. DEncourage the patient to start pushing

看護師が 4 人の患者のケアをしています。定型的なケアとして、看護助手に安全に割り当てられるのは誰ですか？

1. A血糖が 52 mg/dL（2.9 mmol/L）で、汗をかいている患者
2. B手術から戻ってきて、最初の術後アセスメントが必要な患者
3. C脳卒中の 5 日後で、入浴の介助が必要で、バイタルサインが安定している患者
4. D1 時間前に新たに胸腔ドレーンを挿入した患者