解答つき優先順位の決定と委任ワークシート

How many levels does the Emergency Severity Index have?

1. AThree
2. BFour
3. CFive
4. DSix

Which type of stroke is the most common?

1. AHemorrhagic stroke
2. BIschemic stroke
3. CSubarachnoid hemorrhage
4. DVenous sinus thrombosis

In US patient-safety terms (The Joint Commission), what is a sentinel event?

1. AA routine handover between shifts
2. BAn unexpected event that causes death or serious harm
3. CA planned admission to intensive care
4. DA minor error that was noticed but caused no harm at all

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

A patient taking warfarin has an INR of 5.2 and no signs of bleeding. What should the nurse do?

1. AGive a double dose to correct the result
2. BHold the warfarin dose and inform the provider
3. CEncourage the patient to take aspirin for pain
4. DGive the usual dose and recheck the INR next month

A patient is in skeletal traction. Which finding needs the nurse to act?

1. AThe ropes are in the pulleys
2. BThe patient’s body is in line with the traction
3. CThe weights are resting on the floor
4. DThe weights are hanging freely

患者が 45 分前に突然話しにくくなりました。最優先の行動はどれですか？

1. A血栓を抑えるため、すぐにアスピリンを経口投与する
2. Bいつもの朝の薬を飲めるように、水を与える
3. C最後に正常だった時刻を確認し、緊急の画像検査のために脳卒中チームを起動する
4. D朝の病棟回診で神経内科医が診察できるまで待つ

A patient in hypovolemic shock is receiving IV fluids. Which finding best shows that the treatment is working?

1. ACooler, paler skin on the arms and legs
2. BNew crackles at both lung bases
3. CA heart rate that keeps rising after each bag of fluid
4. DUrine output at least 0.5 mL/kg/h and clearer thinking