解答つき優先順位の決定と委任ワークシート

ABC の枠組みで、循環の問題はどれですか？

1. A喘鳴（ストライダー）
2. B不安
3. C止まらない出血
4. D呼吸数 32 回/分

Which patient need belongs to the love and belonging level of Maslow’s hierarchy?

1. ANeeding the call light within reach
2. BWanting family members to visit
3. CWanting praise for progress in rehabilitation
4. DNeeding pain relief after surgery

What does a raised troponin level usually show?

1. ADamage to heart muscle
2. BA urinary tract infection
3. CLow blood sugar
4. DDamage to the liver

A patient taking lisinopril develops swelling of the lips and tongue. What should the nurse do first?

1. AGive the next dose of lisinopril with water
2. BApply a cold pack and recheck in an hour
3. CAssess the airway and call for urgent help
4. DTell the patient this is a common, harmless effect

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. BFlushed, warm skin and a slow heart rate
3. CTall, peaked T waves and muscle twitching
4. DMuscle weakness and U waves on the ECG

ESI を用いたとき、最も高い緊急度レベルになるのはどの患者ですか？

1. A胸痛があり、バイタルサインが正常な患者
2. B足首の骨折の疑いがある患者
3. C3 日間のどが痛く、バイタルサインが正常な患者
4. D反応がなく、あえぐような不規則な呼吸をしている患者

Using ESI, a stable adult with abdominal pain will need blood tests and a CT scan, but has a heart rate of 130/min. Which statement is correct?

1. AThe patient is level 4 because the blood tests and the scan count as one resource
2. BThe patient is level 5 because the pain is not severe
3. CThe nurse should consider level 2 because of the danger-zone vital sign
4. DVital signs never change the ESI level

A nurse sees a colleague put a vial of an opioid into their own pocket instead of returning it. What should the nurse do?

1. AReport it to the nurse manager according to policy
2. BTell the patients to watch the colleague carefully
3. CAsk the colleague to share the vial with them
4. DSay nothing, because it is not their business