解答つき優先順位の決定と委任ワークシート

3 段階のトリアージ分類で、「緊急」にあたる患者はどれですか？

1. A発汗と息切れを伴う胸痛
2. B処方の再発行の依頼
3. Cバイタルサインが正常な、2 日間の腹痛
4. D発熱のない、3 日間の発疹

What is status epilepticus?

1. AA faint caused by standing up too quickly
2. BA seizure lasting 5 minutes or more, or repeated seizures without recovery
3. CA seizure that happens only during sleep
4. DA single short seizure that stops on its own within a minute or two

Which serum potassium result should the nurse report to the provider promptly?

1. A6.4 mEq/L (6.4 mmol/L)
2. B4.2 mEq/L (4.2 mmol/L)
3. C3.8 mEq/L (3.8 mmol/L)
4. D4.9 mEq/L (4.9 mmol/L)

START 法のトリアージで、歩けない成人が 1 分間に 36 回呼吸しています。どの区分になりますか？

1. A黄（待機可能）
2. B緑（軽症）
3. C黒（救命困難）
4. D赤（最優先）

A patient with heart failure gained 2 kg (about 4 lb) since yesterday and is more breathless when lying down. What should the nurse do first?

1. ARecord the weight on the chart and recheck it at the next weekly weigh-in
2. BEncourage extra fluids to correct the weight change
3. CLay the patient flat to help them breathe more easily
4. DAssess the lungs, oxygen saturation and swelling, then inform the provider

A patient taking lithium has vomiting, diarrhea and a new coarse tremor. What should the nurse do?

1. AHold the next dose and report for an urgent lithium level
2. BGive the dose with food to reduce the stomach upset
3. CEncourage the patient to cut down on salt and fluids
4. DReassure the patient that a coarse tremor is expected at first

An 85-year-old resident becomes newly confused and is falling, but has no fever. Which cause should the nurse consider first?

1. AA sudden worsening of long-standing dementia that needs no tests
2. BBoredom from not having enough activities
3. CAn infection, such as a urinary tract infection, presenting atypically
4. DNormal aging that needs no assessment

上部消化管出血の患者の心拍数が 128 回/分、血圧が 84/50 mmHg です。以下はすべて処方されています。看護師が最初に開始するのはどれですか？

1. Aプロトンポンプ阻害薬の静脈内点滴
2. B経口の鉄剤
3. C診断のための内視鏡検査を翌朝に予約すること
4. D太い静脈留置針による輸液または輸血