解答つき優先順位の決定と委任ワークシート

一般に、ほかの問題より先に対処されるのは、どの種類の問題ですか？

1. A退院に向けた学習ニーズ
2. B患者に現在ある顕在的な問題
3. C後で生じるかもしれない潜在的な（リスクの）問題
4. D以前の看護計画に挙げられた問題

看護の優先順位を決める ABC の枠組みでは、どのニーズが最初に対処されますか？

1. A痛み
2. B呼吸（Breathing）
3. C循環（Circulation）
4. D気道（Airway）

When a nurse receives a critical lab result by phone, what does “read-back” mean?

1. AReading the result to the next shift at handover
2. BRepeating the result back to the caller to confirm it
3. CWaiting for the written report before doing anything
4. DReading the result aloud to the patient straight away

A parent of a child with influenza talks with the nurse. Which statement shows a need for further teaching?

1. A“I will give my child plenty of fluids.”
2. B“I will call if my child has trouble breathing.”
3. C“I will keep my child home from school and away from others while unwell.”
4. D“I will give my child aspirin to bring the fever down.”

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

A nurse sees a nursing assistant leave a confused patient’s bed in the highest position after care. What should the nurse do?

1. AWrite it in the assistant’s yearly review only
2. BLower the bed now and remind the assistant why it matters
3. CAsk the family to lower the bed when they next visit
4. DLeave it because the patient is asleep

A patient with SIADH has a serum sodium of 120 mEq/L and is newly confused. Which nursing action has priority?

1. ATeaching the patient about a low-sodium diet at home
2. BSeizure precautions and close neurological checks
3. CHelping the patient to walk in the corridor alone
4. DEncouraging the patient to drink plenty of water

A patient in acute mania paces constantly, has lost weight and will not sit down to eat. Which intervention is most helpful?

1. AWait until the mania settles before worrying about nutrition
2. BLeave meals in the room and let the patient eat whenever and whatever they choose
3. CInsist that the patient sits at the table until the meal is finished
4. DOffer high-calorie finger foods and drinks the patient can take while moving