解答つき優先順位の決定と委任ワークシート

In stroke care, what does the “last known well” time mean?

1. AThe time the first symptom was noticed by a stranger
2. BThe time of the patient’s last meal
3. CThe time the patient arrived at the hospital and was triaged
4. DThe last time the patient was seen without stroke symptoms

What is a “near miss” in patient safety?

1. AA planned treatment that did not work
2. BAn error that reached the patient and caused serious harm
3. CAn error that was caught before it reached the patient
4. DA complaint from a visitor

Which triage method is designed for children in mass-casualty incidents?

1. AJumpSTART
2. BThe Braden Scale
3. CThe Glasgow Coma Scale
4. DThe APGAR score

Several patients on a gastroenterology unit need care. Which patient should the nurse see first?

1. ACrohn disease, waiting to be taken down for a scheduled CT scan
2. BLong-standing back pain, asking for the usual analgesic
3. CUlcerative colitis, asking about diet changes for home
4. DTwo hours after a colonoscopy: rigid abdomen and severe new pain

A patient with mild dysphagia after a stroke is eating. Which technique helps make swallowing safer?

1. ALying flat with the head tilted back
2. BTalking while eating to stay alert
3. CDrinking thin fluids quickly through a straw between bites
4. DSitting upright with the chin tucked down while swallowing

A patient taking warfarin has an INR of 5.2 and no signs of bleeding. What should the nurse do?

1. AEncourage the patient to take aspirin for pain
2. BGive a double dose to correct the result
3. CHold the warfarin dose and inform the provider
4. DGive the usual dose and recheck the INR next month

An adult has burns over 40% of the body with no signs of airway injury. Which treatment is the priority during the first hours?

1. AGiving a high-protein meal to support healing
2. BLarge-volume IV fluids with close monitoring of urine output
3. CApplying antibiotic cream to all the burns before anything else
4. DStarting physiotherapy to prevent contractures straight away

患者が末梢ラインから塩化カリウムの点滴を受けており、刺入部の焼けるような痛みを訴え、その部分が赤くなっています。看護師が最初にすることは何ですか？

1. A点滴を止め、点滴の刺入部をアセスメントする
2. B焼けるような痛みは予測されることだと伝えて、続ける
3. C温罨法を当てて、点滴を続ける
4. D用量を早く終えるために、点滴の速度を上げる