解答つき優先順位の決定と委任ワークシート

Which patient usually fits ESI level 5?

1. AA stable adult who only needs a repeat prescription
2. BA stable adult who needs blood tests and an X-ray of the chest
3. CAn adult in cardiac arrest
4. DAn adult with chest pain suggesting a heart attack

A medication error has just reached a patient. What is the nurse’s first action?

1. ACorrect the entry on the medication record
2. BComplete an incident report before doing anything else
3. CTell the nurse manager at the end of the shift
4. DAssess the patient for any effects of the error

A patient’s platelet count is 18,000/mm³ (18 × 10⁹/L). Which risk is the nursing priority?

1. AFluid overload
2. BBlood clots
3. CInfection
4. DBleeding

On a pediatric unit, which child does the nurse assess first?

1. AA child with croup who has a barking cough but no stridor at rest
2. BA child with asthma who is now quiet with very little air movement
3. CA child with a temperature of 38.2 °C after vaccination
4. DA child in a new arm cast with pink, warm fingers and pain of 5/10

A nursing assistant offers to suction a patient’s new tracheostomy. Which response from the RN is best?

1. A“Leave the suctioning until the next shift arrives.”
2. B“Thank you, please suction him as needed and tell me how it went.”
3. C“Suctioning a new tracheostomy is my task; I will do it myself.”
4. D“Ask the patient’s family to do the suctioning today.”

Which action by a nursing assistant needs the nurse to step in?

1. ACleaning hands before entering the room
2. BTaking an oral temperature just after the patient drank cold water
3. CLowering the bed to its lowest position and locking the wheels after care
4. DPutting the call light within the patient’s reach

A patient is deteriorating quickly. The nurse has called the provider twice, but the provider has not come. What is the best action?

1. AActivate the rapid response team
2. BDocument the concern and continue routine care
3. CAsk the patient’s family to call the provider
4. DWait another hour and call the provider again

A patient admitted with suspected appendicitis says the pain suddenly got better, but now the abdomen is rigid and the heart rate is rising. What does this suggest?

1. AThe appendicitis is getting better without surgery
2. BThe patient’s analgesic has finally started to work
3. CThe appendix may have ruptured, causing peritonitis
4. DThe pain has moved to a different, harmless place