解答つき優先順位の決定と委任ワークシート

3 段階のトリアージ分類で、足首を捻挫し、バイタルサインが正常で軽い痛みのある患者は、通常どのように分類されますか？

1. A緊急（救急）
2. B緊急性なし（非緊急）
3. C準緊急（急ぐ）
4. D救命困難

トリアージとは何ですか？

1. A勤務中の看護師の間で患者を均等に分けること
2. Bベッドの空き状況によって患者を病棟間で移動すること
3. C治療の緊急度によって患者を分類すること
4. D患者を来院順に厳密に治療すること

Which pain scale is designed for infants and young children who cannot describe their pain?

1. AThe FLACC scale
2. BThe Braden Scale
3. CThe Morse Fall Scale
4. DThe Glasgow Coma Scale

Before giving a medication to a child, which check is especially important?

1. AThat the dose is correct for the child’s weight
2. BThat the child likes the taste of the drug
3. CThat the medicine cup is the child’s favorite color
4. DThat the parent agrees with the time it is given

申し送りの後、看護師が最初に診るべき患者はどれですか？

1. A面会者が来る前にシャワーの介助を求めている患者
2. B変形性関節症で、毎朝のこわばりを訴えている患者
3. C新しいギプスをつけて、足の感覚がなくなり、足の指が冷たいと言う患者
4. D利尿薬を使用していて、午前 8 時から 400 mL の尿を出した患者

A nurse teaches a patient who has started warfarin. Which statement shows a need for further teaching?

1. A“I will use a soft toothbrush.”
2. B“I will keep my INR blood test appointments.”
3. C“If I miss a dose, I will take two the next day.”
4. D“I will tell my dentist and pharmacist that I take warfarin.”

During JumpSTART triage, a child who cannot walk is breathing 50 times a minute. Which category is the child given?

1. AYellow (delayed)
2. BGreen (minor)
3. CRed (immediate)
4. DBlack (expectant)

An older patient has bruises of different ages and seems frightened when a relative visits. What is the nurse’s priority?

1. AAsk the relative directly in front of the patient whether they hit her
2. BIgnore it, because older people bruise easily
3. CTell the patient she must leave home and go to live somewhere else
4. DEnsure the patient’s safety, document the findings and report as required