解答つき優先順位の決定と委任ワークシート

Which statement about pulse oximetry is correct?

1. AIt measures the carbon dioxide in the blood
2. BIt shows the patient’s blood glucose
3. CCold fingers or nail polish can give an inaccurate reading
4. DThe reading is always correct, whatever finger or hand is used

Where is intramuscular epinephrine usually injected for anaphylaxis?

1. AThe outer middle thigh
2. BA vein in the hand
3. CThe buttock
4. DThe abdomen under the skin

In most settings, which task is kept for the RN rather than assigned to an LPN/LVN?

1. AGiving scheduled oral medications
2. BMeasuring vital signs
3. CGiving an IV push medication
4. DReinforcing teaching already given

A patient arrives in the recovery room after general anesthesia. What does the nurse assess first?

1. AUrine output
2. BAirway patency and breathing
3. CThe pain score
4. DThe surgical dressing and the drains

Which patient on an addiction unit should the nurse see first?

1. ALast drink one week ago; asking about support groups
2. BLast drink two days ago; now shaking, sweating, heart rate 124/min and seeing insects
3. CIn recovery for a year; came to the clinic today for a routine check and a repeat prescription
4. DLast drink this morning; asking when lunch will arrive

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. AHyperventilation caused by anxiety
2. BToo much bicarbonate from antacids
3. CLoss of bicarbonate from the bowel through severe diarrhea
4. DPoor ventilation causing carbon dioxide to build up

After surgery, a patient who has taken long-term steroids becomes hypotensive and weak, and the blood pressure does not rise with IV fluids. Which problem should the nurse suspect?

1. AAn allergic reaction to the anesthetic
2. BNormal tiredness after anesthesia
3. CFluid overload from too much IV fluid
4. DAdrenal crisis from steroid withdrawal

After a cervical spinal cord injury, a patient has a blood pressure of 80/50 mmHg, a heart rate of 48/min and warm, dry skin. What is most likely?

1. ACardiac tamponade
2. BHypovolemic shock
3. CNeurogenic shock
4. DSeptic shock