解答つき優先順位の決定と委任ワークシート

What is the CIWA scale used to assess?

1. AThe depth of a burn wound
2. BThe severity of alcohol withdrawal
3. CThe severity of a newborn’s jaundice
4. DThe risk of a pressure injury

What is the range of possible scores on the Glasgow Coma Scale?

1. A3 to 15
2. B0 to 15
3. C1 to 20
4. D0 to 10

What does a “PRN” medication order mean?

1. AGive the drug when needed, within the prescribed limits
2. BGive the drug at exactly the same time every single day
3. CGive the drug once only, immediately
4. DGive the drug only before surgery

A nurse teaches a patient to use an incentive spirometer. Which statement shows a need for further teaching?

1. A“I will use it several times every hour while awake.”
2. B“I will breathe in slowly and deeply through the mouthpiece.”
3. C“I will try to hold my breath for a few seconds at the top.”
4. D“I will blow into it as hard and fast as I can.”

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経口抗菌薬で安定している肺炎の患者
2. B新たに気管切開をした患者
3. C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
4. D活動性の上部消化管出血のある患者

A patient with type 1 diabetes has vomited since morning and cannot eat. Which action is most important?

1. AStop all insulin until the patient is able to eat normally again
2. BWait until tomorrow to see if the vomiting settles
3. CEncourage a large meal to settle the stomach
4. DCheck the blood glucose and ketones and contact the provider

After handover on a medical unit, which patient should the nurse see first?

1. ANew atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy
2. BPneumonia on 2 L/min oxygen, SpO₂ 93%, talking in full sentences
3. CDeep vein thrombosis on a heparin infusion, aPTT in the target range
4. DDay 2 after a hernia repair, pain 6/10, oral analgesic due in 20 minutes, wants it now

A patient has a chest drain for a pneumothorax. The nurse sees constant bubbling in the water-seal chamber. What does this most likely mean?

1. AThe lung has fully re-expanded, so the drain is ready to come out
2. BThe drain is working normally and no action is needed
3. CAn air leak in the patient or the system that needs checking
4. DThe suction is set too low and needs to be turned up