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

What does the Morse Fall Scale measure?

1. AA patient’s skin integrity
2. BA patient’s risk of falling
3. CA patient’s nutrition status
4. DA patient’s pain level

Which maneuver opens the airway of an unresponsive adult with no suspected spinal injury?

1. ARaising the legs above the heart
2. BTurning the head sharply to one side
3. CHead-tilt, chin-lift
4. DJaw thrust without head tilt

A drowsy patient has an arterial blood gas with pH 7.30, PaCO₂ 58 mmHg (7.7 kPa) and HCO₃⁻ 25 mEq/L (mmol/L). Which problem is the priority?

1. ALoss of bicarbonate from the bowel through severe diarrhea
2. BHyperventilation caused by anxiety
3. CToo much bicarbonate from antacids
4. DPoor ventilation causing carbon dioxide to build up

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

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

看護師が、過去 1 時間にわたって血圧が下がり続けている患者の定期的なバイタルサインを、看護助手に委任しました。満たされていない委任の正しさはどれですか？

1. A正しい状況
2. Bバイタルサインは決して委任できないので、正しい業務
3. C正しい人
4. D正しい指示とコミュニケーション

After cardiac surgery, a patient becomes hypotensive with distended neck veins and muffled heart sounds, and chest drain output has suddenly stopped. What should the nurse suspect?

1. ALeft-sided heart failure
2. BCardiac tamponade
3. CA blocked urinary catheter
4. DHypovolemic shock from dehydration

A patient has a wrist restraint. The nurse finds the fingers on that hand pale, cool and tingling. What should the nurse do first?

1. ADocument the finding and continue with the medication round
2. BTighten the restraint so the patient moves less
3. CLoosen the restraint and assess the circulation
4. DRaise the arm on a pillow and check again in two hours