解答つき優先順位の決定と委任ワークシート

無料で印刷できる優先順位の決定と委任のワークシート：やさしい問題から試験レベルまで 8 問、解答つき。印刷するか PDF で保存できます。

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名前: ____________________   日付: ____________

1.やさしい

In the ABC framework, which finding is mainly a breathing problem?

  1. AShallow breaths with an SpO₂ of 85% on room air
  2. BHeart rate 150/min with a low blood pressure and cold skin
  3. CStridor caused by a swollen throat
  4. DA blood glucose of 60 mg/dL (3.3 mmol/L)
2.やさしい

Which symptoms suggest high blood glucose (hyperglycemia)?

  1. AIncreased thirst and passing more urine
  2. BConfusion that improves quickly with juice
  3. CSudden hunger with cold, clammy skin
  4. DSweating, shaking and a fast pulse
3.やさしい

A patient’s platelet count is 18,000/mm³ (18 × 10⁹/L). Which risk is the nursing priority?

  1. ABlood clots
  2. BInfection
  3. CFluid overload
  4. DBleeding
4.ふつう

A patient receiving chemotherapy has a temperature of 38.3 °C and a very low neutrophil count. What should the nurse do?

  1. AReport it at once, because cultures and antibiotics are needed quickly
  2. BRecheck the temperature in four hours before telling anyone
  3. CGive a cool shower and offer extra fluids, then wait and see what happens
  4. DDocument the reading and mention it at the next handover
5.ふつう

A patient with heart failure gained 2 kg (about 4 lb) since yesterday and is more breathless when lying down. What should the nurse do first?

  1. AAssess the lungs, oxygen saturation and swelling, then inform the provider
  2. BLay the patient flat to help them breathe more easily
  3. CRecord the weight on the chart and recheck it at the next weekly weigh-in
  4. DEncourage extra fluids to correct the weight change
6.ふつう

Which telephone call should a clinic nurse return first?

  1. AA parent of a 5-year-old with a runny nose for two days
  2. BAn adult who wants to move a routine blood test appointment
  3. CA parent of a 6-week-old with a temperature of 38.3 °C
  4. DAn adult asking for a repeat prescription for a statin
7.むずかしい

A patient with diabetes is sweaty and confused, and no glucose meter is available. The patient can swallow. What should the nurse do?

  1. AAsk the patient to lie down and sleep it off
  2. BWithhold all food and fluids until a meter is found
  3. CTreat for hypoglycemia with fast-acting oral carbohydrate
  4. DGive a dose of rapid-acting insulin in case the glucose is high
8.むずかしい

Which patient finding after a total knee replacement needs the nurse’s action first?

  1. APain of 4/10 when the physiotherapist bends the knee during the morning session
  2. BAsks for an ice pack to help with swelling around the knee
  3. CSudden calf pain and swelling in the operated leg, with new breathlessness
  4. DA small amount of dried blood on the dressing

解答

  1. 1. A · Shallow breaths with an SpO₂ of 85% on room air
  2. 2. A · Increased thirst and passing more urine
  3. 3. D · Bleeding
  4. 4. A · Report it at once, because cultures and antibiotics are needed quickly
  5. 5. A · Assess the lungs, oxygen saturation and swelling, then inform the provider
  6. 6. C · A parent of a 6-week-old with a temperature of 38.3 °C
  7. 7. C · Treat for hypoglycemia with fast-acting oral carbohydrate
  8. 8. C · Sudden calf pain and swelling in the operated leg, with new breathlessness

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