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. BAn adult with chest pain suggesting a heart attack
3. CAn adult in cardiac arrest
4. DA stable adult who needs blood tests and an X-ray of the chest

Which task is appropriate to delegate to a nursing assistant for an immobile but stable patient?

1. ATurning and repositioning the patient every 2 hours
2. BDeciding whether a pressure injury has got worse since yesterday
3. CChoosing which wound dressing to use
4. DPlanning the patient’s skin care

What is the range of possible scores on the Glasgow Coma Scale?

1. A0 to 10
2. B0 to 15
3. C3 to 15
4. D1 to 20

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

A patient receiving IV magnesium sulfate for pre-eclampsia has absent knee reflexes and a respiratory rate of 10/min. What does the nurse do first?

1. AGive oral fluids to help clear the drug faster
2. BIncrease the infusion to prevent a seizure
3. CStop the magnesium infusion and call for help
4. DTurn the patient onto her back and recheck later

A patient at 35 weeks of pregnancy with high blood pressure calls the clinic. Which symptom needs urgent assessment?

1. AMild ankle swelling at the end of the day
2. BA severe headache with blurred vision
3. CNeeding to pass urine more often
4. DBackache after a long walk

An older patient with heart failure is receiving a second unit of blood. She becomes breathless, with crackles in both lungs and a rising blood pressure. What is most likely happening?

1. AAn expected effect of the first unit
2. BTransfusion-associated circulatory overload
3. CA mild allergic reaction with hives
4. DHypoglycemia caused by the stored blood product

During an infusion of a thrombolytic drug for stroke, the patient develops a severe headache and starts vomiting. What should the nurse do first?

1. AContinue the infusion, because headache is expected
2. BSlow the infusion and give an antiemetic as prescribed
3. CStop the infusion and inform the provider at once
4. DGive a dose of aspirin for the headache