解答つき優先順位の決定と委任ワークシート

What is the purpose of the “time-out” just before a surgical procedure?

1. ATo give the surgeon a short rest before the operation starts
2. BTo let the family say goodbye to the patient
3. CTo count the swabs at the end of the operation
4. DTo confirm the correct patient, procedure and site

優先順位の問題で、アセスメントと行動の両方が選択肢にあるとき、緊急でない状況では、通常どちらが先に正解になりますか？

1. A患者を診る前に医療者に連絡する
2. B看護助手に患者の様子を見に行かせる
3. C患者をアセスメントして、情報を集める
4. D懸念を記録に書く

マズローの欲求階層を用いるとき、看護師が通常、最初に対処する患者の問題はどれですか？

1. A夜間の転倒リスク
2. B社会的孤立
3. Cガス交換障害
4. D自尊感情の低下

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

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

On day 3 after hip surgery, a patient suddenly becomes short of breath with sharp chest pain and an SpO₂ of 88%. What should the nurse do first?

1. ARaise the head of the bed, give oxygen and call for urgent help
2. BMassage the patient’s calves to ease any muscle cramp
3. CEncourage the patient to walk to improve the circulation
4. DGive the next dose of oral analgesia and reassess the patient in an hour

A patient on a medical unit tells the nurse he has a plan to end his life and has saved tablets at home. What is the priority action?

1. AArrange a psychiatry appointment for next week
2. BReassure him that things usually look better in the morning after some sleep
3. CEnsure constant observation and remove anything he could use to harm himself
4. DAsk him to promise he will not harm himself

A patient with anorexia nervosa is admitted. Which finding is the priority?

1. ASays she feels fat although she is very thin
2. BRefuses to eat in front of other people
3. CHas fine, downy hair on her arms
4. DHeart rate 38/min and potassium 2.8 mEq/L

Which patient with cirrhosis should the nurse see first?

1. AVomiting bright red blood, heart rate 120/min
2. BLarge ascites that is unchanged from yesterday
3. CLong-standing jaundice and itchy skin, asking for cream
4. DWants to talk about stopping drinking alcohol for good