解答つき優先順位の決定と委任ワークシート

In which situation can a pulse oximeter give a falsely normal reading?

1. AA warm, well-perfused finger
2. BA patient breathing room air normally
3. CCarbon monoxide poisoning
4. DA healthy adult at rest

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

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

3 段階のトリアージ分類で、「緊急」にあたる患者はどれですか？

1. A処方の再発行の依頼
2. B発熱のない、3 日間の発疹
3. C発汗と息切れを伴う胸痛
4. Dバイタルサインが正常な、2 日間の腹痛

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股関節置換術の 2 日後で、痛みが 5/10 の患者
2. B肺炎で体温 38.2 °C だが、30 分前に解熱薬を投与された患者
3. C朝食前の血糖が 160 mg/dL（8.9 mmol/L）の糖尿病患者
4. D補助呼吸筋を使い、SpO₂ が 88 % の喘息患者

A patient arrives in the recovery room after general anesthesia. What does the nurse assess first?

1. AUrine output
2. BThe surgical dressing and the drains
3. CAirway patency and breathing
4. DThe pain score

Which practice makes a shift handover safest?

1. AA quick chat in the corridor with no notes taken
2. BHanding over only the patients who had problems during the shift
3. CLeaving a sticky note on the computer screen for the next nurse
4. DA structured format, such as SBAR, with time for questions

After a vaginal birth, the uterus is firm and central, but bright red blood keeps trickling steadily. What should the nurse suspect?

1. AUterine atony that needs more massage
2. BA tear in the birth canal or cervix
3. CNormal lochia for the first hour
4. DA full bladder pushing the uterus aside

An older adult with type 2 diabetes is confused and very dehydrated. The glucose is 900 mg/dL (50 mmol/L), and blood and urine show no significant ketones. What is the most likely problem?

1. AHyperosmolar hyperglycemic state
2. BStress-induced mild hyperglycemia
3. CDiabetic ketoacidosis
4. DHypoglycemia with rebound