解答つき優先順位の決定と委任ワークシート

トリアージとは何ですか？

1. A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
2. B勤務中の看護師の間で患者を均等に分けること
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

In the ABC framework, which finding is mainly a breathing problem?

1. AShallow breaths with an SpO₂ of 85% on room air
2. BA blood glucose of 60 mg/dL (3.3 mmol/L)
3. CStridor caused by a swollen throat
4. DHeart rate 150/min with a low blood pressure and cold skin

Which patient usually fits ESI level 5?

1. AA stable adult who only needs a repeat prescription
2. BAn adult with chest pain suggesting a heart attack
3. CA stable adult who needs blood tests and an X-ray of the chest
4. DAn adult in cardiac arrest

A patient with a valid do-not-resuscitate order (DNR; called DNACPR in the UK) stops breathing and has no pulse. What should the nurse do?

1. AStart CPR and stop when the family arrives
2. BFollow the DNR order and do not start CPR
3. CStart chest compressions but not rescue breaths
4. DCall the cardiac arrest team and let them decide

A child with fever and headache develops a purple rash that does not fade when pressed with a glass. What should the nurse do?

1. AAdvise the family to see their doctor next week
2. BTreat it as an emergency and escalate at once
3. CApply a soothing cream to the rash
4. DGive acetaminophen (paracetamol) and reassess in four hours

Five days after starting heparin, a patient’s platelet count has fallen by more than half. What should the nurse suspect?

1. AHeparin-induced thrombocytopenia
2. BAn expected effect that needs no action
3. CVitamin K deficiency
4. DIron deficiency anemia

住宅火災から救出された患者に、顔面の熱傷、鼻毛の焦げ、嗄声があります。優先すべきことは何ですか？

1. A気道を守り、早期の気道確保に備える
2. B熱傷の面積から計算した、輸液蘇生を開始する
3. C顔面の熱傷を洗浄してドレッシングを貼る
4. D鎮痛を行う

A patient’s serum potassium is 6.1 mEq/L. Which of the patient’s medications should the nurse question first?

1. AHydrochlorothiazide
2. BSpironolactone
3. COmeprazole
4. DFurosemide