解答つき優先順位の決定と委任ワークシート

A patient has a Glasgow Coma Scale score of 8. What is the main concern?

1. AThe patient is fully alert and oriented
2. BThe patient only has a mild headache
3. CThe patient can safely eat and drink without help
4. DThe patient may not be able to protect the airway

What does the Braden Scale measure?

1. AThe risk of developing a pressure injury
2. BThe severity of alcohol withdrawal symptoms
3. CThe level of consciousness after a head injury
4. DThe risk of falling during a hospital stay

Which white blood cell count suggests an infection or inflammation?

1. A7,000/mm³ (7 × 10⁹/L)
2. B6,500/mm³ (6.5 × 10⁹/L)
3. C8,200/mm³ (8.2 × 10⁹/L)
4. D18,000/mm³ (18 × 10⁹/L)

A conscious patient with hypoglycemia drank juice 15 minutes ago. The glucose is now 62 mg/dL (3.4 mmol/L). What should the nurse do next?

1. AWait another hour, because juice can take a long time to work
2. BGive another serving of fast-acting carbohydrate and recheck in 15 minutes
3. CRecord the result and recheck the glucose at the usual time before the evening meal
4. DGive the next scheduled dose of rapid-acting insulin with the meal

A nursing assistant tells the RN that a patient’s IV pump is alarming. What is the best response?

1. A“Silence the alarm and I will check it at the end of the shift.”
2. B“I will come and check the pump and the IV site now.”
3. C“Turn the pump off and on again until it stops.”
4. D“Increase the rate a little so the alarm clears.”

A patient on a medical unit tells the nurse he has a plan to end his life and has saved tablets at home. What is the priority action?

1. AAsk him to promise he will not harm himself
2. BEnsure constant observation and remove anything he could use to harm himself
3. CArrange a psychiatry appointment for next week
4. DReassure him that things usually look better in the morning after some sleep

A patient admitted with suspected appendicitis says the pain suddenly got better, but now the abdomen is rigid and the heart rate is rising. What does this suggest?

1. AThe appendix may have ruptured, causing peritonitis
2. BThe patient’s analgesic has finally started to work
3. CThe pain has moved to a different, harmless place
4. DThe appendicitis is getting better without surgery

A patient with a head injury has a pupil on one side that is now large and does not react to light. What should the nurse do?

1. ARecheck it at the next routine observation in four hours
2. BDocument it, because pupils often differ slightly after a head injury
3. CDim the room lights so the pupil can get smaller
4. DReport it at once, as it may mean the brain is being compressed