解答つき優先順位の決定と委任ワークシート

Which finding is expected in a patient with long-standing COPD?

1. ANew confusion
2. BSudden sharp chest pain
3. CA barrel-shaped chest
4. DAn SpO₂ of 78%

Which protective equipment is needed for airborne precautions?

1. AA plastic apron only
2. BGloves only
3. CA fit-tested N95 or FFP3 respirator
4. DA simple surgical mask worn loosely

What should the nurse try before using physical restraints on a confused patient?

1. AUsing restraints at once and removing them later if they turn out not to be needed
2. BLess restrictive measures, such as more frequent checks or a bed alarm
3. CAsking the family to bring restraints from home
4. DRestraining all four limbs to be fully safe

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

After a hip replacement using a posterior approach, which statement shows a need for further teaching?

1. A“I will not bend my hip past 90 degrees.”
2. B“I will use a raised toilet seat at home.”
3. C“I will cross my legs when I sit, so I am more comfortable.”
4. D“I will keep a pillow between my knees when I lie on my side in bed.”

看護師（RN）が看護助手に「12 号室の患者さんを見てきて」と伝えました。委任の正しさのうち、欠けているのはどれですか？

1. A正しい状況
2. Bその業務に正しい人
3. C正しい指示とコミュニケーション
4. D現場に合った正しい業務

A patient with diabetic ketoacidosis is about to start an IV insulin infusion. The serum potassium is 3.0 mEq/L. What should the nurse do?

1. AReport the result before starting, because insulin will push potassium even lower
2. BGive the insulin as a fast bolus to bring the potassium up
3. CIgnore the result, since potassium is always high in this condition and will correct itself
4. DStart the insulin at once, because the glucose is the bigger problem

A patient arrives one hour after the start of stroke symptoms. Which step must happen before a thrombolytic drug can be given?

1. AA full lipid profile to check cholesterol
2. BA brain scan to rule out bleeding
3. CAn echocardiogram to look for clots
4. DA swallow test with a cup of water