解答つき優先順位の決定と委任ワークシート

In the FAST stroke check, what does the T stand for?

1. ATemperature
2. BTremor of the hands
3. CTime to call emergency services
4. DTongue movement

What are Kussmaul respirations?

1. ANoisy, high-pitched breathing caused by a blocked upper airway
2. BShort pauses in breathing during normal sleep
3. CDeep, rapid breathing seen in metabolic acidosis such as DKA
4. DSlow, shallow breathing after an opioid overdose

What does a root cause analysis look for after a serious event?

1. AThe single staff member who should be blamed
2. BHow much the event cost the hospital
3. CThe underlying system causes of the event
4. DWhich patient made the complaint

A patient with a spinal cord injury at T4 suddenly has a severe headache, flushing above the injury and a blood pressure of 200/110 mmHg. What does the nurse do first?

1. AGive a warm drink and recheck the blood pressure in an hour
2. BSit the patient upright with the legs lowered
3. CApply extra blankets to keep the patient warm and calm
4. DLay the patient flat with the legs raised

A drowsy patient has an arterial blood gas with pH 7.30, PaCO₂ 58 mmHg (7.7 kPa) and HCO₃⁻ 25 mEq/L (mmol/L). Which problem is the priority?

1. APoor ventilation causing carbon dioxide to build up
2. BToo much bicarbonate from antacids
3. CHyperventilation caused by anxiety
4. DLoss of bicarbonate from the bowel through severe diarrhea

A nurse teaches a patient who uses home oxygen. Which statement shows a need for further teaching?

1. A“I will keep the oxygen away from the gas stove.”
2. B“I will put up no-smoking signs at the front door and in my room.”
3. C“I will not use oil-based creams on my face.”
4. D“My husband can smoke in my room if the window is open.”

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

A 2-month-old infant has a spiral fracture of the femur. The parents say the baby rolled off the sofa. What should the nurse recognize?

1. ANo further action is needed once the fracture is treated
2. BThe injury does not fit the infant’s development, so possible abuse must be reported
3. CA spiral fracture in an infant is always caused by birth trauma
4. DInfants of this age often roll off furniture and break bones in this way