解答つき優先順位の決定と委任ワークシート

アセスメント、看護の判断、評価を必要とする業務は、どうすべきですか？

1. A常に LPN/LVN に委任する
2. B患者の家族に任せる
3. C看護師（RN）が行う
4. D最も経験豊富な看護助手に委任する

マズローの階層の安全の段階に属する患者のニーズはどれですか？

1. A酸素
2. B友情
3. C転倒からの保護
4. D他者からの承認

Which finding meets the usual definition of orthostatic hypotension?

1. ASystolic pressure falls by 20 mmHg or more within 3 minutes of standing
2. BBlood pressure is the same lying and standing
3. CHeart rate falls by 5/min after lying down
4. DSystolic pressure rises by 20 mmHg or more within 3 minutes of standing up

A young adult has just started an SSRI antidepressant for major depression. What should the nurse monitor most closely in the first weeks?

1. AWeight loss from too much appetite
2. BThoughts of suicide or self-harm
3. CHair growth and skin color
4. DRising blood glucose levels

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

普段は産科で働く看護師が、成人の内科病棟に応援に入ります。この看護師に割り当てるのに最も適切な患者はどれですか？

1. A糖尿病性ケトアシドーシスのためにインスリンを持続点滴している患者
2. B活動性の上部消化管出血のある患者
3. C新たに気管切開をした患者
4. D経口抗菌薬で安定している肺炎の患者

A patient who is 7 weeks pregnant has one-sided lower abdominal pain, pain in the shoulder tip, a heart rate of 120/min and a blood pressure of 88/54 mmHg. What is most likely?

1. AA ruptured ectopic pregnancy
2. BA normal early pregnancy
3. CSevere morning sickness
4. DA urinary tract infection

A patient with known abdominal aortic aneurysm suddenly has severe back pain, a pulsing mass in the abdomen and a falling blood pressure. What should the nurse do?

1. ACall for emergency help at once and prepare for urgent surgery
2. BEncourage the patient to walk to ease the back pain
3. CPalpate the mass firmly to check its size and spread
4. DGive an oral analgesic and reassess the patient in about one hour