解答つき優先順位の決定と委任ワークシート

In the United States, which law sets out the scope of nursing practice in each state?

1. AThe state Nurse Practice Act
2. BThe Food and Drug Administration rules
3. CThe federal tax code
4. DThe hospital’s visitor policy

Which adult blood glucose result needs treatment straight away?

1. A98 mg/dL (5.4 mmol/L) before breakfast
2. B52 mg/dL (2.9 mmol/L) with sweating and shakiness
3. C130 mg/dL (7.2 mmol/L) two hours after a large lunch
4. D110 mg/dL (6.1 mmol/L) after a snack

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

1. A3.8 mEq/L (3.8 mmol/L)
2. B4.2 mEq/L (4.2 mmol/L)
3. C6.4 mEq/L (6.4 mmol/L)
4. D4.9 mEq/L (4.9 mmol/L)

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

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

A swimmer is found unresponsive after diving into shallow water. Which method should the nurse use to open the airway?

1. ARaising the chin while bending the neck forward
2. BTurning the head to the side to drain water
3. CJaw thrust, keeping the head and neck in line
4. DHead-tilt, chin-lift with full neck extension

A patient has a reddened area on the sacrum that does not blanch when pressed. What is the priority action?

1. AKeep the patient lying on the back to protect the area
2. BRelieve pressure on the area by changing position regularly
3. CMassage the area firmly to improve the blood flow to the skin
4. DApply a heat pad to the area to increase circulation

申し送りの後、看護師が最初にアセスメントすべき患者はどれですか？

1. A胆嚢手術の 2 日後：痛みが 6/10 で、次の鎮痛薬は 30 分後に予定されている
2. B酸素 2 L/分を使用している COPD：SpO₂ 90 %、呼吸数 22 回/分で、普段のベースライン
3. C大腿動脈からの心臓カテーテル検査の 1 時間後：新たな背部痛、脈拍 118 回/分、血圧 92/58 mmHg
4. D2 型糖尿病：昼食前の血糖が 210 mg/dL（11.7 mmol/L）で、症状はない

A patient with SIADH has a serum sodium of 120 mEq/L and is newly confused. Which nursing action has priority?

1. AEncouraging the patient to drink plenty of water
2. BTeaching the patient about a low-sodium diet at home
3. CSeizure precautions and close neurological checks
4. DHelping the patient to walk in the corridor alone