解答つき優先順位の決定と委任ワークシート

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

1. AThe APGAR score
2. BJumpSTART
3. CThe Braden Scale
4. DThe Glasgow Coma Scale

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

1. AHigh, suggesting fluid overload
2. BExpected after drinking fluids
3. CNormal for an adult at rest
4. DLow and needing to be reported

Which serum creatinine result suggests reduced kidney function in an adult?

1. A3.5 mg/dL (about 310 µmol/L)
2. B0.7 mg/dL (about 60 µmol/L)
3. C1.0 mg/dL (about 90 µmol/L)
4. D0.8 mg/dL (about 70 µmol/L)

Which patient on an addiction unit should the nurse see first?

1. ALast drink one week ago; asking about support groups
2. BIn recovery for a year; came to the clinic today for a routine check and a repeat prescription
3. CLast drink two days ago; now shaking, sweating, heart rate 124/min and seeing insects
4. DLast drink this morning; asking when lunch will arrive

看護師が最後に診ても安全な患者はどれですか？

1. A新たな湿性ラ音とピンク色の泡沫状の痰がある患者
2. B1 L/分の酸素を使用し、SpO₂ 90 %（目標 88～92 %）で、文章で会話できる COPD の患者
3. C手術の 2 時間後で、心拍数が 88 から 118 回/分に上昇している患者
4. D突然の激しい頭痛がある患者

Which patient is most suitable for the nurse to assign to a nurse who has just finished orientation?

1. AA patient with sepsis whose blood pressure is falling
2. BA patient with a new tracheostomy who needs frequent suctioning
3. CA patient on a continuous heparin infusion with rising aPTT values
4. DA patient with stable cellulitis on scheduled IV antibiotics

A severely malnourished patient started nutrition two days ago and now has weakness and confusion. Which laboratory result should the nurse check first?

1. ASerum amylase
2. BThyroid hormone
3. CSerum phosphate
4. DSerum cholesterol

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

1. AFurosemide
2. BHydrochlorothiazide
3. CSpironolactone
4. DOmeprazole