解答つき優先順位の決定と委任ワークシート

ABC の枠組みで、循環の問題はどれですか？

1. A不安
2. B呼吸数 32 回/分
3. C喘鳴（ストライダー）
4. D止まらない出血

In the Emergency Severity Index (ESI), which patient fits level 2?

1. AA patient who needs an immediate life-saving intervention to survive
2. BA high-risk situation, new confusion, or severe pain or distress
3. CA stable patient who needs no resources
4. DA stable patient who needs one resource

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

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

A patient uses patient-controlled analgesia (PCA) after surgery. Which statement by a family member shows a need for further teaching?

1. A“I will press the button for her while she is asleep so she stays comfortable.”
2. B“The pump has limits set by the nurse so she cannot get too much at once.”
3. C“Only she should press the button when she needs pain relief.”
4. D“I will tell the nurse if she becomes very sleepy or hard to wake.”

Before giving a scheduled dose of metoprolol, which assessment is most important?

1. AApical pulse and blood pressure
2. BBowel sounds and urine color
3. CBlood glucose and weight
4. DTemperature and the latest pain score

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

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

A patient with COPD on 2 L/min oxygen becomes drowsy and hard to wake. The SpO₂ is 93%. What is the priority?

1. ALet the patient sleep, because the saturation is above target
2. BGive the as-needed sedative so the patient rests comfortably
3. CIncrease the oxygen to 6 L/min so that the saturation goes even higher than now
4. DAssess breathing and escalate for a blood gas, as carbon dioxide may be rising

After a head injury, a patient has clear fluid dripping from the nose. Which action should the nurse avoid?

1. AInserting a tube or suction catheter through the nose
2. BChecking the fluid for glucose or a halo sign on gauze
3. CInforming the provider about the drainage
4. DPlacing a loose gauze under the nose