解答つき優先順位の決定と委任ワークシート

A patient’s urine output is 15 mL/h for three hours. How should the nurse classify this in an adult?

1. AExpected after drinking fluids
2. BNormal for an adult at rest
3. CLow and needing to be reported
4. DHigh, suggesting fluid overload

大量傷病者のトリアージで、赤のタグは通常何を意味しますか？

1. A最優先（即時）：生命に関わるが、速やかな処置で救命可能
2. B救命困難：処置をしても生存の見込みが低い、またはすでに死亡している
3. C待機可能（遅延）：重傷だが、当面は安定している
4. D軽症：歩行可能で、安全に待てる

Which strategy helps a nurse organize care at the start of a shift?

1. ADo the tasks in strict order of room number, whatever their urgency
2. BWait until problems come up and then decide what to do
3. CRank the tasks by urgency after report and plan the time around them
4. DDo the quickest tasks first so the list gets shorter

One day after surgery, a patient walked safely with the RN this morning. The RN now asks a nursing assistant to walk her again. Which instruction is most important?

1. A“Try to finish the walk before the lunch trays arrive.”
2. B“Stop and call me at once if she feels dizzy or short of breath.”
3. C“Walk her to the end of the corridor and back twice before lunch.”
4. D“Make sure she wears her own slippers if she has them.”

A parent calls to say their toddler has just swallowed drain cleaner. What should the nurse advise?

1. AGive a large glass of fizzy drink or milk to dilute the cleaner before calling anyone
2. BMake the child vomit straight away to bring up the chemical
3. CWait to see whether the child develops any symptoms first
4. DDo not make the child vomit; call poison control or emergency services now

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. BCall the cardiac arrest team and let them decide
3. CFollow the DNR order and do not start CPR
4. DStart chest compressions but not rescue breaths

A competent adult patient refuses a blood transfusion for religious reasons. What should the nurse do?

1. ARespect the refusal, check the patient understands the risks and inform the provider
2. BAsk the family to persuade the patient until they agree
3. CTell the patient that refusing treatment is not allowed in hospital
4. DGive the transfusion while the patient is asleep, because saving their life comes first

A trauma patient has an open leg fracture, absent breath sounds on one side, a trachea shifted to the other side and a falling blood pressure. Which problem is the priority?

1. AThe pain from the fracture
2. BThe suspected tension pneumothorax
3. CThe open fracture of the leg
4. DThe risk of wound infection