解答つき優先順位の決定と委任ワークシート

Which finding should a nursing assistant report to the nurse at once?

1. AA pulse of 42/min in a patient whose usual pulse is 76/min
2. BA patient who would like tea instead of coffee
3. CA patient whose weight is unchanged from yesterday
4. DA patient who wants to shower in the evening

Which protective equipment is needed for droplet precautions?

1. AGloves only, with no mask
2. BA surgical mask when close to the patient
3. CA fitted N95 respirator at all times in the room
4. DA lead apron and goggles

In mass-casualty triage, what does a yellow tag usually mean?

1. AMinor: the walking wounded
2. BDelayed: serious injuries, but care can safely wait a little
3. CDeceased or not expected to survive
4. DImmediate: life-threatening injuries that are survivable with quick care

A woman calls to say her husband suddenly has a drooping face and slurred speech. What should the nurse advise?

1. ADrive him to the hospital yourself after he has eaten dinner
2. BLet him lie down and see if it improves
3. CBook an appointment with his doctor next week
4. DCall emergency services now and note the time it started

A patient is receiving opioids after surgery. Which finding usually comes before opioid-induced respiratory depression?

1. AIncreased appetite and thirst
2. BIncreasing sleepiness that is hard to rouse
3. CA rise in blood pressure with flushed cheeks
4. DA sudden rise in pain scores

During a blood transfusion, a patient develops chills, back pain and a fever. What is the nurse’s first action?

1. ASlow the transfusion and recheck in an hour
2. BFinish the unit quickly through a pressure bag so that the reaction does not last long
3. CGive an antipyretic and continue the transfusion
4. DStop the transfusion and keep the IV open with normal saline via new tubing

A victim heavily contaminated with an industrial chemical arrives at the emergency department with stable vital signs. What should happen first?

1. APlacing the victim in the waiting room until a doctor is free
2. BDecontamination before the victim enters the treatment area
3. CTaking the victim straight to the X-ray department
4. DFull assessment inside the main department straight away

A patient in hypovolemic shock is receiving IV fluids. Which finding best shows that the treatment is working?

1. ANew crackles at both lung bases
2. BCooler, paler skin on the arms and legs
3. CUrine output at least 0.5 mL/kg/h and clearer thinking
4. DA heart rate that keeps rising after each bag of fluid