解答つき優先順位の決定と委任ワークシート

What are Kussmaul respirations?

1. AShort pauses in breathing during normal sleep
2. BSlow, shallow breathing after an opioid overdose
3. CDeep, rapid breathing seen in metabolic acidosis such as DKA
4. DNoisy, high-pitched breathing caused by a blocked upper airway

Which capillary refill time is prolonged in an adult?

1. A2 seconds
2. B1 second
3. CLess than 1 second
4. D4 seconds

A patient’s respiratory rate is 30/min at rest. How should the nurse classify this finding in an adult?

1. AWithin the normal adult range
2. BNormal after a meal
3. CAbnormally fast and needing assessment
4. DSlow, and expected while the patient is asleep

A patient with a head injury is being monitored. Which set of findings suggests rising intracranial pressure?

1. ARising systolic pressure, slow pulse and irregular breathing
2. BNormal blood pressure, normal pulse and clear speech
3. CFalling blood pressure, a fast pulse and warm, flushed dry skin
4. DLow temperature, fast breathing and a strong appetite

A patient receiving an aminoglycoside antibiotic, such as gentamicin, reports ringing in the ears. What should the nurse do?

1. AHold the next dose and report it promptly
2. BGive the next dose early to finish the course
3. CAdvise the patient to use ear drops
4. DReassure the patient that it is a normal effect

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. APoor ventilation causing carbon dioxide to build up
2. BToo much bicarbonate from antacids
3. CHyperventilation caused by anxiety
4. DLoss of bicarbonate from the bowel through severe diarrhea

チームに RN、LPN/LVN、看護助手がいます。最も適切な割り当てはどれですか？

1. A助手：新規入院、LPN/LVN：清潔ケア、RN：安定した患者の定期的なバイタルサイン
2. BLPN/LVN：すべての初期アセスメント、RN：定時の与薬、助手：退院指導
3. CRN：新規入院、LPN/LVN：安定した患者への与薬、助手：清潔ケア
4. D助手：経口薬、LPN/LVN：看護計画、RN：安定した患者の清潔ケア

A patient is going home on a new oral anticoagulant. There is only a short time for teaching. Which topic is most important?

1. AHow to cook low-fat meals
2. BHow to choose comfortable walking shoes
3. CSigns of bleeding and when to seek help
4. DWhich television programs help with relaxation