1.やさしい
What are Kussmaul respirations?
- ANoisy, high-pitched breathing caused by a blocked upper airway
- BShort pauses in breathing during normal sleep
- CDeep, rapid breathing seen in metabolic acidosis such as DKA
- DSlow, shallow breathing after an opioid overdose
2.やさしい
Which term describes a patient who is unable to understand and decide about their own care?
- AFully competent
- BProviding valid informed consent
- CLacking decision-making capacity
- DExercising autonomy
3.やさしい
What is the main purpose of a rapid response team?
- ATo review medication errors and falls after they have happened on the unit
- BTo assess and treat a deteriorating patient before an arrest happens
- CTo handle complaints from patients and families
- DTo transport stable patients between hospital units
4.ふつう
A nurse gives IV morphine for severe pain. When should the nurse reassess the pain and sedation?
- AWithin about 15–30 minutes
- BOnly when the patient asks for more
- CAt the next routine round in four hours
- DAt the end of the shift
5.ふつう
One day after surgery, a patient walked safely with the RN this morning. The RN now asks a nursing assistant to walk her again. Which instruction is most important?
- A“Walk her to the end of the corridor and back twice before lunch.”
- B“Stop and call me at once if she feels dizzy or short of breath.”
- C“Make sure she wears her own slippers if she has them.”
- D“Try to finish the walk before the lunch trays arrive.”
6.ふつう
RN が LPN/LVN に委任するのに最も適切な業務はどれですか?
- A安定した患者への留置カテーテルの挿入
- Bインスリンを新しく始めた患者への退院指導
- C新規患者の入院時アセスメント
- D最初の赤血球製剤の開始
7.むずかしい
患者が末梢ラインから塩化カリウムの点滴を受けており、刺入部の焼けるような痛みを訴え、その部分が赤くなっています。看護師が最初にすることは何ですか?
- A点滴を止め、点滴の刺入部をアセスメントする
- B温罨法を当てて、点滴を続ける
- C用量を早く終えるために、点滴の速度を上げる
- D焼けるような痛みは予測されることだと伝えて、続ける
8.むずかしい
看護助手への委任として適切なものはどれですか?
- A最初の栄養の前に、新たに挿入した経鼻胃管の位置を確認すること
- B輸血の最初の 15 分間、患者を観察すること
- C脳卒中のあと、嚥下スクリーニングがまだ済んでいない患者に、最初の食事を提供すること
- D安定した患者の定期的な尿検体の採取
解答
- 1. C · Deep, rapid breathing seen in metabolic acidosis such as DKA
- 2. C · Lacking decision-making capacity
- 3. B · To assess and treat a deteriorating patient before an arrest happens
- 4. A · Within about 15–30 minutes
- 5. B · “Stop and call me at once if she feels dizzy or short of breath.”
- 6. A · 安定した患者への留置カテーテルの挿入
- 7. A · 点滴を止め、点滴の刺入部をアセスメントする
- 8. D · 安定した患者の定期的な尿検体の採取
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