解答つき優先順位の決定と委任ワークシート

What does the Braden Scale measure?

1. AThe risk of falling during a hospital stay
2. BThe level of consciousness after a head injury
3. CThe risk of developing a pressure injury
4. DThe severity of alcohol withdrawal symptoms

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

Why may a full-thickness burn feel painless at its center?

1. AThe nerve endings in the skin have been destroyed
2. BThe burn only affects the thin surface layer of the skin
3. CThe patient has been given too much fluid
4. DThe burn has already fully healed

A nurse teaches a patient with heart failure. Which statement shows a need for further teaching?

1. A“I will take my water tablet in the morning.”
2. B“I will call if my weight goes up quickly over a day or two.”
3. C“I add extra salt to my food so it tastes better.”
4. D“I will weigh myself every morning after I use the toilet.”

看護助手が、訓練を受けていないとして、委任された業務を断りました。看護師の最もよい対応はどれですか？

1. A職務記述書に書かれているので、やらなければならないと伝える
2. B訓練を受けた人がいる次の勤務帯まで、業務を残しておく
3. C助手に感謝し、業務が安全に行われるようにして、訓練を手配する
4. D業務を断ったとして、助手を管理者に報告する

内科の混合病棟で、看護師が最初に診るべき患者はどれですか？

1. A明日の退院についての書面の情報を求めている患者
2. Bアセトアミノフェンを求めている、軽い緊張型頭痛の患者
3. C持ち物を人にあげ、自殺の計画をもっている、うつ病の患者
4. D血圧が 136/84 mmHg の高血圧の患者

A child is admitted with a suspected Wilms tumor (nephroblastoma). Which instruction is most important for all staff?

1. AMeasure abdominal girth by pressing firmly
2. BGive a warm bath with abdominal massage
3. CDo not palpate the abdomen
4. DEncourage the child to play contact sports

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. BAsk the patient’s family to call the provider
3. CDocument the concern and continue routine care
4. DWait another hour and call the provider again