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。
格拉斯哥昏迷评分(GCS)多少分表示患者完全清醒?
测量了卧位和立位血压。哪项结果符合直立性低血压的通常定义?
Which room lighting is safest at night for a patient at high risk of falls?
Which patient with a suspected infection meets the qSOFA criteria that signal a higher risk of a poor outcome?
A malnourished patient admitted with alcohol use disorder needs IV glucose. Which vitamin is given before or with it?
An infant is choking and cannot cry or breathe. Which technique is correct?
Which examination findings suggest a large pleural effusion on one side?
哪项护理评估最有助于及早发现大手术后患者的病情恶化?
对于疑似脓毒症的患者,应在何时采集血培养?
A patient's low calcium does not improve despite several days of calcium replacement. Which other electrolyte should be checked and corrected?
A patient is due the first dose of IV cefuroxime. Which question is most important before giving it?
奥美拉唑等质子泵抑制剂的主要作用机制是什么?
哪项实验室检查用于调整普通肝素的输注?
Four hours after abdominal surgery, a patient's heart rate has risen from 84 to 122/min and they are restless and pale. BP is still 118/76 mmHg, and the surgical drain is filling with blood. What should the nurse conclude?
Why is pyridostigmine often taken about 30–60 minutes before meals by patients with myasthenia gravis?
After a stroke, a patient suddenly cries or laughs at odd moments. They say they do not feel sad. Which response is most appropriate?
Why do patients usually have a dental review before radiotherapy to the head and neck?
A few hours after thyroid surgery, a patient's neck swells rapidly and they become short of breath with stridor. What is most likely?
A woman at 22 weeks describes sharp pain on one side of the lower abdomen when she stands up quickly. Her vital signs and fetal heart rate are normal. What is the most likely cause?
A woman in active labour has been at 6 cm for 4 hours despite regular contractions. Which factor among the "5 Ps" should the nurse consider first?
A 6-year-old with a life-limiting illness asks the nurse, "Am I going to die?" What is the best response?
A family with a 2-year-old has a swimming pool in the garden. Which measure gives the most protection against drowning?
A patient taking valproate is starting lamotrigine. Why must lamotrigine be increased especially slowly?
A patient taking venlafaxine has started a second serotonergic medicine. She is restless, sweating, has a fast pulse and twitching muscles. What should the nurse do first?
练习题(虚构数值,不作为临床指导)。 一次小剂量注射的计算得到 0.32871 mL。 本练习的规则是:低于 1 mL 的体积取到最接近的百分之一 mL。你记录的数值x是多少?
练习题(虚构数值,不作为临床指导)。 一个班次中,患者摄入了½ tbsp / 液体营养补充剂, 3 杯 / 茶, 1 fl oz / 果汁, 2½ tsp / 止咳糖浆。按给出的等量关系,求以 mL 表示的口服总摄入量V。
某患者体重 12 kg,医嘱为单次给药 10 mg/kg。求剂量 D(mg)。
处方为 1950 单位的药物,药液规格为 5000 单位/mL。请用 1 mL 注射器抽取剂量:应给多少体积 V?
用滴系数为 20 滴/mL 的输液器在 4 小时内输入 1000 mL。求滴速 R(滴/分)。 取整到最接近的整数。
一袋液体在 250 mL 中含药 400 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)。 一份输液含普通胰岛素 250 单位,容量 250 mL。医嘱为 10 units/h。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)。 一袋中含dobutamine 500 mg,容量 250 mL。医嘱为 2.5 mcg/kg/min,患者体重 98 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)。 记录显示了一名患者在一个 12 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。求总入量 I,以 mL 计。 冰屑按其体积的一半计。
练习题(虚构数值,不作为临床指导)。 一份 1000 mL 的输液于 20:00 开始以 80 mL/h 输注。2 小时后速率改为 60 mL/h,之后不再改变。从开始算起多少小时 t 后袋子会输完? 保留一位小数。
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 16 次/分,SpO₂ 88%吸室内空气,血压 90/54 mmHg,脉搏 70 次/分,清醒,体温 35.2 °C。NEWS2 总分是多少?
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 9 次/分,SpO₂ 97%吸室内空气,血压 96/58 mmHg,脉搏 70 次/分,清醒,体温 35.5 °C。患者属于哪个临床风险组?点击它。
某练习血气显示 PaCO₂ 26 mmHg (3.5 kPa)。利用规则:在慢性呼吸性碱中毒中,PaCO₂ 每比 40 低出 10 mmHg,HCO₃⁻ 下降 5 mmol/L,以HCO₃⁻ 24 mmol/L 为起点,求预期HCO₃⁻。
某练习血气显示呼吸性酸中毒:pH 7.30,PaCO₂ 77 mmHg (10.3 kPa),HCO₃⁻ 37 mmol/L。利用规则“HCO₃⁻ 每 10 mmHg 升高 1 mmol/L(急性)或 3.5 mmol/L(慢性)”进行分类。点选你的答案。
解读这条 II 导联心律条带。这是什么节律?点击你的答案。
识别这条 II 导联心电图上的节律。点击你的答案。
答案: B · 15
GCS 范围为 3 分(深昏迷)到 15 分(完全清醒)。8 分及以下通常意味着气道有危险。
答案: A · 站立后 3 分钟内收缩压下降 20 mmHg 或以上
直立性低血压通常定义为站立后 3 分钟内收缩压下降至少 20 mmHg 或舒张压下降至少 10 mmHg。它是跌倒评估中的重要发现。
答案: B · A low night light that lights the path to the bathroom
A night light lets the patient see obstacles and the way to the bathroom without disturbing sleep. Many falls happen in the dark on the way to the toilet.
答案: B · Respiratory rate 24/min, new confusion, systolic BP 95 mmHg
qSOFA scores one point each for a respiratory rate of 22/min or more, altered mental status and a systolic BP of 100 mmHg or less. Two or more points mean higher risk, so the first patient needs urgent escalation.
答案: D · Thiamine (vitamin B1)
Thiamine deficiency is common in heavy alcohol use, and giving glucose without thiamine can trigger Wernicke encephalopathy. Thiamine is given before or with glucose.
答案: A · Back blows and chest thrusts
For a choking infant, the nurse gives cycles of five back blows and five chest thrusts. Abdominal thrusts are not used in infants, and blind finger sweeps can push the object deeper.
答案: C · Dull percussion and reduced breath sounds over the lung base
Fluid in the pleural space muffles breath sounds and makes percussion stony dull. A large effusion may push the trachea away from the affected side.
答案: B · 定期测量全套生命体征,使用早期预警评分并评估变化趋势
NEWS2 等"追踪与触发"系统综合呼吸频率、SpO2、血压、脉搏、意识和体温,以便及早识别病情恶化。
答案: B · 在首剂抗生素之前,且不要过多延误给药
血培养应在使用抗生素之前采集,因为即使一剂抗生素也可能使细菌无法生长而掩盖病因。抗生素仍应尽快开始,最好在一小时内。核对依据: Sepsis · MedlinePlus (NIH) (2024)
答案: A · Magnesium
Low magnesium reduces parathyroid hormone secretion and the body's response to it, so hypocalcemia does not correct until magnesium is replaced. The same applies to refractory hypokalemia.核对依据: Magnesium Blood Test · MedlinePlus (NIH) (2023)
答案: C · "Have you ever had a reaction to penicillin or another antibiotic?"
Allergy history must be checked before any first antibiotic dose. Cephalosporins share the beta-lactam ring with penicillins, so a history of severe penicillin allergy is important.
答案: D · 不可逆地抑制壁细胞的 H⁺/K⁺-ATP 酶
PPI 不可逆地阻断质子泵,即胃酸分泌的最后一步。H2 受体阻滞剂(如法莫替丁)作用较早、效力较弱;抗酸药只能中和。
答案: D · aPTT(或抗 Xa 水平)
静脉普通肝素的效应不稳定,应按处方方案根据 aPTT(或抗 Xa 水平)滴定。同时还应检查血小板计数,以发现肝素诱导的血小板减少症。D-二聚体用于帮助排除血栓形成,而不是监测治疗。
答案: D · Early haemorrhagic shock is likely, so escalate urgently
Rising heart rate, restlessness, pallor and visible bleeding are signs of compensated haemorrhagic shock. Waiting for hypotension delays treatment. The nurse escalates urgently, gives oxygen, ensures IV access and anticipates bloods, fluids or blood products and surgical review.
答案: D · To improve the strength of chewing and swallowing at mealtimes
Pyridostigmine inhibits acetylcholinesterase, so more acetylcholine is available at the neuromuscular junction. Timing it before meals gives the best muscle strength for chewing and swallowing, which lowers the risk of aspiration.
答案: D · Explain that this is emotional lability after stroke and help the family understand
Emotional lability (pseudobulbar affect) is common after stroke: crying or laughter does not match the person's mood. Explaining it, staying calm and gently distracting the patient helps. True depression is also common and should be screened for separately.
答案: A · It causes dry mouth and raises the risk of decay and jaw damage
Head and neck radiotherapy damages salivary glands, causing xerostomia and dental decay, and can cause osteoradionecrosis of the jaw after extractions. Dental treatment is done first, with careful oral hygiene and fluoride.
答案: A · A haematoma pressing on the airway
A haematoma after thyroid or neck surgery can compress the airway quickly. It is an emergency: call for help, sit the patient up and give oxygen, and follow local guidance on opening the wound to release the clot.
答案: A · Round ligament pain
Round ligament pain is sharp, brief pain in the groin or lower abdomen with sudden movement as the uterus grows. Moving slowly and flexing the hips towards the abdomen help. Persistent or severe pain needs review.
答案: B · The passenger: fetal size, position or presentation
When contractions are adequate but labour stalls, causes include a malpositioned or large fetus (passenger) or a narrow pelvis (passageway). Position changes, hydration and support of the psyche can also help progress.
答案: C · Find out what prompted the question, then answer honestly and simply, with the family
Children with serious illness often sense what is happening. Exploring the question ("What makes you ask?") and answering honestly, at the child's level and in agreement with the family, reduces isolation and fear. False reassurance damages trust.
答案: B · A four-sided fence with a self-closing, self-latching gate, plus constant supervision
Isolation fencing that fully separates the pool from the house and garden, combined with active adult supervision, is the most effective protection. Flotation aids and lessons do not replace supervision, and toddlers cannot reliably follow safety rules.
答案: A · Valproate raises lamotrigine levels, which increases the risk of a serious rash
Valproate inhibits the metabolism of lamotrigine, roughly doubling its levels. Because lamotrigine rash, including Stevens-Johnson syndrome, is linked to rapid dose increases, a slower titration is used.
答案: C · Hold the serotonergic medicines and inform the prescriber urgently
These signs suggest serotonin syndrome. The first steps are to stop the serotonergic drugs and get urgent medical review; supportive care and monitoring follow, and severe cases need intensive care.
答案: x = 0.33 mL
取整:看舍入位后面的那个数字:5 或更大则进位,4 或更小则保持原数字不变。只对最终答案取整,绝不对中间步骤取整。典型的考试规则:1 mL 或以上的体积取到十分位,低于 1 mL 的体积取到百分位,滴速取整到整滴,体重取到一位小数;务必遵循题目所规定的规则。
答案: V = 770 mL
家用计量和体重:护理考试使用取整的等量关系:1 茶匙(tsp)= 5 mL,1 汤匙(tbsp)= 15 mL = 3 tsp,1 液量盎司(fl oz)= 30 mL = 2 tbsp,1 杯 = 8 fl oz = 240 mL。体重方面,1 kg = 2.2 lb,1 lb = 16 oz;长度方面,1 英寸 = 2.54 cm。设置换算时,要让你不需要的单位相互约去。
答案: D = 120 mg
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: V = 0.39 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 1 mL 的注射器上,每条小刻度线代表 0.01 mL。
答案: R = 83 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:83 滴/分。
答案: D = 32 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 = 10 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 = 7.4 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。
答案: I = 1340 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。
答案: t = 16 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 16 h 00 min,所以袋子大约在 12:00 输完。
答案: NEWS2 = 7
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: 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: HCO₃⁻ = 17 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。
答案: 慢性
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。
答案: 交界性心律
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: 心室颤动
室性节律:室性心动过速是连续三个或以上宽大(0.12 s 或以上)的波群,频率超过 100 次/分,通常为 150–250 次/分,节律规则,没有相关的 P 波。心室颤动是紊乱、不规则的波形,无法辨认 P 波、QRS 波群或 T 波,也没有可计数的频率。心脏停搏是几乎平直的线,没有心室活动;平直线一定要通过检查患者、导联和增益并换一个导联来确认。在复苏指南中,室颤和无脉性室速是可电击心律,心脏停搏则不是。
在复苏指南中,室颤和无脉性室速是可电击心律。这里只是识别练习。
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