感染控制与患者安全
方法
- 对每位患者都从标准预防开始:手卫生、针对预期暴露的个人防护装备、安全使用锐器。
- 按传播途径追加预防措施:接触传播(隔离衣、手套)、飞沫传播(外科口罩)、空气传播(N95、负压病房)。
- 保持无菌物品的无菌状态:如有疑问就视为不无菌;更换,绝不擦拭。
- 预防环境中的伤害:防跌倒措施,约束仅作为最后手段,火灾时用 RACE 和 PASS。
- 核对给药的正确原则、两个身份识别信息,以及对高警示药物的额外保障;报告差错和险兆事件。
公式表、每个专题的关键方法步骤和 40 道练习题,完整解答附在最后。
While wearing sterile gloves, where should the nurse keep their hands?
For a patient at risk of pressure ulcers, why is the head of the bed usually kept at 30 degrees or less if their condition allows?
Which IV fluid can be given with packed red blood cells in the same line?
A patient restrained because of violent behavior is now calm, oriented and following instructions. What should the nurse do?
护士可以放心最后去看哪位患者?
A patient is going home on a new oral anticoagulant. There is only a short time for teaching. Which topic is most important?
Which features suggest pyelonephritis rather than simple cystitis?
A patient with known cirrhosis suddenly vomits large amounts of bright red blood and becomes tachycardic. What is the most likely cause?
一名服用华法林的患者开始每天大量食用羽衣甘蓝和菠菜。INR 已下降。哪项建议最恰当?
A patient with long-term heavy alcohol use is admitted with alcohol withdrawal. Which group of electrolyte problems is most common?
Which statement about allopurinol is correct?
Which statement correctly contrasts donepezil and memantine in Alzheimer's disease?
Septic shock belongs to which category of shock?
The monitor shows a regular broad-complex tachycardia at 180/min. The patient is alert with BP 126/78 mmHg and no chest pain. What is the most appropriate plan?
How does the nurse test the facial nerve (VII)?
Which task for a patient with a urinary catheter can the nurse delegate to a healthcare assistant (nursing assistant)?
Which burn should usually be discussed with a specialist burns service even if it is small?
During burn resuscitation, a 70 kg adult's urine output has been 120 mL/h for 3 hours, and the face and limbs are very oedematous. What should the nurse do?
Which finding in a term newborn's first hours is normal?
The nurse must deliver a baby before the provider arrives. As the head crowns, what should the nurse do?
A child receiving chemotherapy has painful mouth ulcers (mucositis). Which mouth care is best?
After hypospadias repair, a toddler has a urinary catheter. Which nursing action has priority?
Which nursing action at mealtimes is most appropriate for a patient with anorexia nervosa?
An 80-year-old patient taking a benzodiazepine for sleep fell at night on the way to the toilet. After checking her for injury, what is the most appropriate next step?
练习题(虚构数值,不作为临床指导)。 一位患者的体温为 36.8 °C。用 °F = °C × 9/5 + 32 把它换算为华氏度T。取到一位小数。
练习题(虚构数值,不作为临床指导)。 一次输注的给药速率为 5 mg/h。请把这个剂量速率D用 mcg/min 表示。取到一位小数。
一名体重 39 kg 的儿童按 5 mg/kg 处方用药。原液浓度为 25 mg/mL。请抽取剂量:应给多少体积 V?
一袋输液在 1000 mL 中含 40000 单位药物。医嘱为每小时 500 单位。泵速 R 应设为多少 mL/h?
用滴系数为 10 滴/mL 的输液器在 2 小时内输入 500 mL。求滴速 R(滴/分)。 取整到最接近的整数。
一袋液体在 100 mL 中含药 200 mg,以 20 mL/h 的速度输注。患者每小时获得多少毫克 D?
练习题(虚构数值,不作为临床指导)。 一袋中含肝素 20 000 单位,容量 500 mL。医嘱为 20 units/kg/h,患者体重 65 kg。输液泵速率 R 应设为多少 mL/h? 保留一位小数。
练习题(虚构数值,不作为临床指导)。 一名体重 58 kg 的患者的医嘱为nitroglycerin 10 mcg/min。输液袋中含 25 mg,容量 250 mL。求泵速 R,以 mL/h 计。 保留一位小数。
练习题(虚构数值,不作为临床指导)。 记录显示了一名患者在一个 8 小时班次中的出入量。静脉输液在整个班次中按所示速率输注。求液体平衡 B = 入量 − 出量,以 mL 计(答案为负表示净丢失)。
练习题(虚构数值,不作为临床指导)。 一袋 1000 mL 的液体用输液泵以 75 mL/h 输注。到 20:30 时已输入 600 mL。还要多少小时 t 袋子才会输完? 保留一位小数。
练习题(虚构数值,不作为临床指导)。 用 Morse 跌倒评分评估一位练习患者:过去 3 个月内的跌倒史: 是; 次要诊断: 否; 行走辅助: 拐杖、手杖或助行器; 静脉输液或封管: 是; 步态: 虚弱; 精神状态: 高估或忘记自身局限。求 Morse 总分MFS。
练习题(虚构数值,不作为临床指导)。 对这些观察结果使用 NEWS2 图表(SpO₂ 量表 1):呼吸频率 24 次/分,SpO₂ 97%正在补充吸氧,血压 136/82 mmHg,脉搏 64 次/分,清醒,体温 36.4 °C。患者属于哪个临床风险组?点击它。
某练习动脉血气显示 pH 7.37,PaCO₂ 27 mmHg (3.6 kPa),HCO₃⁻ 15 mmol/L。原发性紊乱是代谢性酸中毒。代偿到什么程度?点选你的答案。
练习数值:Na⁺ 134,Cl⁻ 99,HCO₃⁻ 17 mmol/L,白蛋白 26 g/L。求经白蛋白校正的阴离子间隙 AGc = AG + 0.25·(40 − 白蛋白)。
解读这条 II 导联心律条带。这是什么节律?点击你的答案。
这条 II 导联心电图显示房室传导阻滞,所以心房和心室以不同的频率搏动。测量 P–P 间期,求出心房率(单位:次/分,1500 法,取整数)。
答案: A · Above waist level and in sight
Sterile hands are kept in front of the body, above the waist and within sight, so accidental contamination is noticed. The edge of the field is not sterile.
答案: A · Higher angles make the patient slide down, causing shear over the sacrum
When the head is raised high, the body tends to slide while the skin stays still, distorting the tissues over the sacrum. Keeping the angle low, where safe, reduces this shear.
答案: A · 0.9% sodium chloride
Only 0.9% sodium chloride is compatible with blood. Dextrose (glucose) solutions can cause red cells to clump and break down, and the calcium in lactated Ringer’s (Hartmann’s) can cause clotting.
答案: A · Remove the restraints, because the reason for them has ended
Restraints are used only as long as needed to keep people safe. Once the patient no longer presents a danger, the restraints are removed, even if the order has not yet expired.
答案: A · 一名 COPD 患者,吸氧 1 L/min,SpO₂ 90%(目标 88–92%),能说完整的句子
这名 COPD 患者在规定的目标范围内且感觉舒适,因此是稳定的。术后心率上升、肺水肿征象和突发剧烈头痛都需要及时评估。
答案: D · Signs of bleeding and when to seek help
The main risk of anticoagulants is bleeding, so the patient must know the signs, such as black stools or blood in the urine, and when to seek help. Other topics can follow later.
答案: A · Fever, rigors and loin pain
Pyelonephritis is an upper urinary tract infection and causes systemic signs such as fever and rigors, with flank pain. Cystitis usually causes local symptoms such as dysuria and frequency.
答案: D · Bleeding from ruptured oesophageal varices
Portal hypertension in cirrhosis causes oesophageal varices, which can bleed massively. This needs resuscitation, urgent endoscopy and specific drug treatment.
答案: B · 保持富含维生素 K 的食物摄入量每天稳定
维生素 K 拮抗华法林,因此叶类蔬菜大量增加会使 INR 降低。患者不必避免这些食物,但应保持摄入量一致,以便正确设定剂量。核对依据: Warfarin · MedlinePlus (NIH) (2026); Taking warfarin · MedlinePlus (NIH) (2025)
答案: A · Low magnesium, low phosphate and low potassium
Poor diet, vomiting, diarrhea and alcohol's effect on the kidneys commonly cause low magnesium, phosphate and potassium. These worsen arrhythmia and seizure risk, so they are checked and replaced, together with thiamine.
答案: A · It lowers uric acid over time and does not relieve the pain of an acute attack
Allopurinol reduces urate production and is taken daily to prevent attacks. Acute attacks are treated with NSAIDs, colchicine or corticosteroids, and a new rash on allopurinol must be reported.
答案: A · Donepezil inhibits cholinesterase; memantine blocks NMDA receptors
Donepezil raises acetylcholine levels, while memantine reduces excitotoxic glutamate activity at NMDA receptors. Both give symptomatic benefit only.
答案: A · Distributive shock
In distributive shock (septic, anaphylactic, neurogenic), vessels dilate and leak, so blood is maldistributed and pressure falls. Obstructive shock includes PE, tamponade and tension pneumothorax; cardiogenic shock is pump failure; hypovolaemic shock is volume loss.
答案: B · Record a 12-lead ECG, call senior help and anticipate an antiarrhythmic
A broad-complex tachycardia is treated as ventricular tachycardia until proven otherwise. With a pulse and no adverse features (shock, syncope, chest pain or heart failure), a 12-lead ECG, electrolyte correction and drug treatment such as amiodarone are used, with expert help. Unstable patients need synchronised cardioversion; pulseless VT is defibrillated.
答案: B · Ask them to raise the eyebrows, shut the eyes tightly and smile
The facial nerve moves the muscles of the face. Asking the patient to raise the eyebrows, close the eyes, puff the cheeks and smile shows any weakness. Facial sensation is carried by the trigeminal nerve.
答案: A · Emptying the drainage bag and recording the volume
Emptying and recording urine volume is routine and can be delegated to trained staff. Decisions about removal, assessment of a possible blockage and first-time teaching need the registered nurse.
答案: A · A partial-thickness burn on the hand
Burns of the face, hands, feet, genitalia, perineum and major joints, as well as circumferential, chemical, electrical and inhalation injuries, usually need specialist advice because of their risks and functional impact.
答案: A · Discuss reducing the fluid rate with the team
An output of about 1.7 mL/kg/h suggests over-resuscitation. Excess fluid ("fluid creep") worsens oedema and can cause pulmonary oedema and compartment syndromes, so the rate is reviewed and reduced under the burn protocol.
答案: C · Short breathing pauses with no colour change
Newborns breathe irregularly, with short pauses of a few seconds and no change in colour or heart rate. Apnoea of 20 seconds or more, or any pause with cyanosis or bradycardia, is abnormal.
答案: B · Apply gentle pressure to the head to slow the birth
Gentle pressure on the fetal head, with the woman panting, slows birth and reduces perineal tearing and rapid pressure changes in the fetal skull. The nurse then checks for a nuchal cord and supports the baby's body.
答案: D · A soft toothbrush or sponge, bland rinses and soft, cool foods
Gentle cleaning with a soft brush or sponge, regular saline or bland rinses, analgesia and soft, cool, non-acidic foods protect the mouth. Alcohol mouthwashes and lemon–glycerine swabs dry and irritate the mucosa.
答案: A · Keep the catheter draining freely and check for kinks or blockage
After repair, the catheter or stent protects the new urethra while it heals. It must drain freely; blockage causes bladder spasm and pressure on the repair. Fluids are encouraged, and the dressing is managed as the surgeon directs.
答案: A · Supervise the meal and observe the patient for an agreed period afterwards
Supervised meals and observation afterwards reduce hiding or discarding food, vomiting and excessive exercise. Mealtimes should be calm, with conversation that is not focused on food or weight.
答案: B · Report the fall, put falls precautions in place and ask for a review of her sleep medicine
Benzodiazepines increase the risk of falls in older adults. After a fall, the nurse reports it, reduces risks such as poor lighting and the distance to the toilet, and asks for a medication review.
答案: T = 98.2 °F
温度:°C = (°F − 32) × 5/9,°F = °C × 9/5 + 32。从 °F 换算时先减 32 再乘,从 °C 换算时先乘再加 32。快速核对:37 °C 为 98.6 °F,每 1 °C 相当于 1.8 °F。
答案: D = 83.3 mcg/min
量纲分析:先写出已知量,再乘以写成分数形式的换算系数(例如 60 min/1 h 或 1 mg/1000 mcg),使每个不需要的单位在分子和分母各出现一次并相互约去。只剩下所求单位时再计算。使用题目给出的等量关系,只对最终答案取整。
答案: V = 7.8 mL
抽取剂量:体积 = (处方剂量/药物浓度) × 药物体积。先换算成相同的单位,再检查该体积是否适合注射器,并落在它的某一个刻度上。
在这支 10 mL 的注射器上,每条小刻度线代表 0.2 mL。
答案: R = 12.5 mL/h
剂量计算:给药量等于医嘱剂量除以现有药物的规格,再乘以该规格对应的量:给药量 = (医嘱剂量/储备规格) × 储备体积。始终统一单位(先把 g 换成 mg,mg 换成 mcg),并检查答案是否合理。
答案: R = 42 gtt/min
输注速率:输液泵按 mL/h = 体积/时间(小时)设定。重力滴注按每分钟滴数计:gtt/min = 体积 (mL) × 滴系数 (gtt/mL)/时间 (min)。 滴系数印在输液器包装上:普通输液器为 10、15 或 20 gtt/mL(输血器在美国常为 10 gtt/mL,在英国为 15),微量输液器为 60 gtt/mL。务必使用题目或包装给出的滴系数。
床旁取最接近的整滴:42 滴/分。
答案: D = 40 mg/h
输注速率:输液泵按 mL/h = 体积/时间(小时)设定。重力滴注按每分钟滴数计:gtt/min = 体积 (mL) × 滴系数 (gtt/mL)/时间 (min)。 滴系数印在输液器包装上:普通输液器为 10、15 或 20 gtt/mL(输血器在美国常为 10 gtt/mL,在英国为 15),微量输液器为 60 gtt/mL。务必使用题目或包装给出的滴系数。
答案: R = 32.5 mL/h
肝素和胰岛素输注:浓度 = 袋中单位数/袋容量 (units/mL)。泵速 (mL/h) = 每小时单位数/浓度,每小时单位数 = mL/h × 浓度。按体重给药时,先求 units/h = units/kg/h × 体重。推注体积 = 所需单位数/药瓶规格。 这些数字仅供练习;在临床工作中务必遵循当地规程,高危剂量须经双人核对。
答案: R = 6 mL/h
滴定输注:先求以 mcg/mL 计的浓度(mg × 1000/mL)。按体重给药时,mcg/min = mcg/kg/min × 体重。然后 mL/h = mcg/min × 60/浓度。反推时,mcg/kg/min = mL/h × 浓度/(60 × 体重)。 这些数字仅供练习;在临床工作中务必遵循当地规程,高危剂量须经双人核对。
医嘱是针对患者整体的每分钟剂量,所以不需要体重。
答案: B = 365 mL
出入量:入量计入所有进入体内的液体(口服液体、静脉输液、静脉用药及冲管液、管饲);冰屑按其体积的一半计。出量计入尿液、引流液、呕吐物和其他丢失。平衡 = 总入量 − 总出量;平衡为负表示净丢失。 这些数字仅供练习;在临床工作中务必遵循当地规程,高危剂量须经双人核对。
为正:摄入的液体多于排出的液体。
答案: t = 5.3 h
输液时间:时间 (h) = 待输体积 (mL)/速率 (mL/h);使用袋中剩余的体积,而不是袋的容量。已输入体积 = 速率 × 时间。把小数小时换算为小时和分钟时,用小数部分 × 60(0.5 h = 30 min,而不是 50 min)。 这些数字仅供练习;在临床工作中务必遵循当地规程,高危剂量须经双人核对。
约为 5 h 20 min,所以袋子大约在 01:50 输完。
答案: MFS = 85
Morse 跌倒评分:六个条目。跌倒史:否 0 分,是 25 分。次要诊断:否 0 分,是 15 分。行走辅助:无、卧床休息或护士协助 0 分;拐杖、手杖或助行器 15 分;扶着家具 30 分。静脉输液或封管:否 0 分,是 20 分。步态:正常、卧床休息或轮椅 0 分;虚弱 10 分;受损 20 分。精神状态:了解自身局限 0 分;高估或忘记自身局限 15 分。总分为 0 至 125。各医院的风险分界值不同;常用的一套是 0–24 低风险,25–44 中度风险,45 及以上为高风险。
答案: 低
NEWS2(国家早期预警评分 2,英国皇家内科医师学会 2017):按图表为七个参数分别评分(呼吸频率、量表 1 的 SpO₂、吸空气还是吸氧、收缩压、脉搏、按 ACVPU 量表评定的意识状态和体温),然后把分数相加。临床风险:0–4 为低;任何单项参数得 3 分为中低;5–6 为中;7 或以上为高。总分 5 或以上需要紧急响应。
答案: 完全代偿
解读血气(ROME):先看 pH:低于 7.35 为酸血症,高于 7.45 为碱血症。然后找出能解释它的指标。PaCO₂(正常 35–45 mmHg,4.7–6.0 kPa)是呼吸方面的指标,在呼吸性紊乱中与 pH 反向(Opposite)变化;HCO₃⁻(正常 22–26 mmol/L)是代谢方面的指标,与 pH 同向变化(Respiratory Opposite, Metabolic Equal,即呼吸性相反,代谢性相同)。另一个指标显示代偿情况:正常表示未代偿;沿着使 pH 回升的方向异常、而 pH 仍然异常,表示部分代偿;pH 正常而两个指标都异常,表示完全代偿。各实验室的范围略有差异;这些是练习用数值。
临床上还应检查预期代偿:按温特公式,预期 PaCO₂ 为 28.5–32.5 mmHg,所以实测 27 mmHg 提示合并呼吸性碱中毒(混合性紊乱)。上面的答案是按 ROME 法的考试分类。
答案: AGc = 21.5 mmol/L
预期代偿:代谢性酸中毒时,温特公式预测 PaCO₂ = 1.5·HCO₃⁻ + 8 ± 2 mmHg;实测值高于该范围提示合并呼吸性酸中毒,低于该范围提示合并呼吸性碱中毒。阴离子间隙 AG = Na⁺ − (Cl⁻ + HCO₃⁻),正常约为 8–12 mmol/L,用于区分高阴离子间隙与正常阴离子间隙代谢性酸中毒;低白蛋白会掩盖升高的间隙(白蛋白低于 4.0 的部分,每 g/dL 加 2.5)。Δ 比值 (AG − 12)/(24 − HCO₃⁻) 约在 0.8 到 2 之间符合单纯高间隙酸中毒(有些教材用 1 代替 0.8),低于此范围提示合并正常间隙酸中毒,高于 2 提示合并代谢性碱中毒。
校正后高于约 12:阴离子间隙升高。
答案: 心房颤动
节律标准(II 导联):窦性心律每个 QRS 之前都有直立的 P 波,PR 恒定为 0.12–0.20 s,QRS 狭窄:60–100 次/分为正常窦性心律,低于 60 为窦性心动过缓,高于 100 为窦性心动过速。心房颤动:无 P 波,基线呈颤动,R–R 绝对不规则。心房扑动:约 250–350 次/分的锯齿状扑动波,伴固定的传导比例,如 2:1 或 4:1。一度房室传导阻滞:窦性心律,PR 恒定且大于 0.20 s。交界性心律:窄 QRS,40–60 次/分,P 波缺失或倒置(PR 低于 0.12 s,或 P 波在 QRS 之后)。室性早搏(PVC)是提前出现的宽大(0.12 s 或以上)、形态怪异的 QRS,没有 P 波,T 波方向相反,通常有完全性代偿间歇;二联律是指每隔一个搏动就有一个室性早搏。
答案: 心房率 = 79 bpm
房室传导阻滞:逐个标出 P 波,检查哪些 P 波后面跟着 QRS。一度:每个 P 波都下传,PR 恒定且大于 0.20 s。二度 I 型(Mobitz I,文氏现象):PR 逐搏延长,直到一个 P 波未下传,然后周期重新开始(成组搏动)。二度 II 型(Mobitz II):下传搏动的 PR 保持恒定,P 波突然不下传;QRS 常增宽。三度(完全性)阻滞:P 波和 QRS 波群各自规则但互相独立,PR 随机变化,心房率快于逸搏率(交界性逸搏 40–60 次/分,QRS 窄;室性逸搏 20–40 次/分,QRS 宽)。2:1 阻滞仅凭一份条带无法判断是 I 型还是 II 型。
三度阻滞,伴窄 QRS 交界性逸搏(通常为 40–60 次/分)。
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