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。
Which nursing record entry is the best example of objective documentation?
According to current European (ERC) and 2025 American Heart Association guidelines, what is the first action for a conscious adult who is choking and cannot cough effectively?
Where is a gait belt placed when helping a patient to walk?
A nurse teaches new parents about safe infant sleep. Which statement shows a need for further teaching?
对护理助理的哪项指示最清楚?
At the end of a shift, the nurse’s relief has not arrived and the patients are acutely ill. What should the nurse do?
Why does a patient with a suspected TIA need urgent specialist assessment?
A patient who used sildenafil the day before develops chest pain. Why is glyceryl trinitrate (GTN, nitroglycerin) normally avoided?
During a red cell transfusion, when are serious acute reactions most likely, so the nurse stays with the patient?
A patient has a positive hepatitis C antibody (anti-HCV) test. What is the most appropriate next step?
Methylergometrine (methylergonovine) is prescribed for postpartum bleeding. Which finding would make the nurse withhold it and check with the prescriber?
A 19-year-old woman is starting isotretinoin for severe acne. Which requirement is most important?
根据现行指南,急性冠脉综合征患者何时应给氧?
一名服用阿哌沙班治疗心房颤动的患者已预约择期手术。下列哪项说法体现了正确做法?
Which statement about the PSA blood test is correct?
A nurse teaches the family of a patient on insulin how to manage a severe hypo. Which statement shows a need for further teaching?
Which statement about giving medicines through a feeding tube is correct?
一名患有慢性肾脏病的 74 岁患者术后剧烈疼痛。哪个阿片类药物问题最重要?
Which factors help start the newborn's first breath?
A labouring woman has had an epidural for 3 hours. The fundus is displaced and a bulge is seen above the pubic bone. What should the nurse do?
Which instruction about using an adrenaline (epinephrine) auto-injector is correct?
A 5-year-old insists that a tall, thin glass holds more juice than a short, wide glass, although he saw the same amount poured into each. What explains this?
How does aripiprazole differ from most other antipsychotics?
A patient who is detained under mental health legislation refuses his prescribed oral antipsychotic. What is the correct general principle?
练习题(虚构数值,不作为临床指导)。 一个剂量记录在 00:00(24 小时制)。哪个条目是 12 小时制中的同一时间?点击它。
练习题(虚构数值,不作为临床指导)。 一个班次中,患者摄入了1 杯 / 茶, 1½ tsp / 止咳糖浆, ½ tbsp / 液体营养补充剂, 1½ fl oz / 果汁。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 25 kg,医嘱为单次给药 20 mg/kg。求剂量 D(mg)。
一名体重 16 kg 的儿童,医嘱为口服混悬液每次 12.5 mg/kg,该混悬液每 5 mL 含 200 mg。你应给多少体积 V?
用滴系数为 60 滴/mL 的输液器在 5 小时内输入 500 mL。求滴速 R(滴/分)。
一组输液以 30 滴/分的速度经 20 滴/mL 的输液器滴注。袋中还剩 900 mL。还需多少小时 t 才会滴完?
练习题(虚构数值,不作为临床指导)。 一份输液含普通胰岛素 100 单位,容量 250 mL。医嘱为 8 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dopamine 400 mg,容量 250 mL。医嘱为 2 mcg/kg/min,患者体重 88 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 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 18:00 时已输入 350 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: 是; 行走辅助: 拐杖、手杖或助行器; 静脉输液或封管: 是; 步态: 正常、卧床休息或轮椅; 精神状态: 了解自身局限。求 Morse 总分MFS。
练习题(虚构数值,不作为临床指导)。 一名成人体重 130 kg,身高 186 cm。计算 BMI 并点击 WHO 体重分类。
某练习动脉血气显示 pH 7.56,PaCO₂ 23 mmHg (3.1 kPa),HCO₃⁻ 20 mmol/L。原发性紊乱是呼吸性碱中毒。代偿到什么程度?点选你的答案。
某练习血气显示呼吸性酸中毒:pH 7.28,PaCO₂ 64 mmHg (8.5 kPa),HCO₃⁻ 29 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: C · "Ate half of lunch; drank 200 mL of water."
Objective entries describe what was observed or measured. Vague or judgemental phrases such as "good" or "as usual" cannot be checked or compared.
答案: D · Give up to 5 back blows
For severe airway obstruction in a conscious adult, give up to 5 back blows, then up to 5 abdominal thrusts if needed, and repeat. Older US teaching started with abdominal thrusts alone. If they become unresponsive, start CPR.
答案: A · Around the patient’s waist, over clothing
The gait belt goes snugly around the waist over clothing, close to the center of gravity, with room for the nurse’s fingers underneath. Holding it gives control without pulling on the arms.
答案: B · “We will put a soft bumper pad and a blanket in the crib so the baby is cozy.”
Soft bedding, bumpers and loose blankets increase the risk of suffocation and sudden infant death. The crib should hold only a firm mattress with a fitted sheet.
答案: D · “10:00 测李先生的血压,如果收缩压低于 100,立即告诉我。”
最好的指示确切说明做什么、何时做,以及哪些数值必须立即报告。其他指示让助理去猜什么才重要。
答案: B · Stay and tell the charge nurse, and hand over before leaving
The nurse must not leave patients without handing over to another qualified nurse. Telling the charge nurse allows staffing to be arranged safely.
答案: A · The risk of a full stroke is highest in the days after a TIA
The risk of stroke is highest soon after a TIA. Rapid assessment and treatment, such as antiplatelets, statins and carotid imaging, reduce this risk.
答案: A · The combination can cause a severe, dangerous fall in blood pressure
PDE5 inhibitors such as sildenafil enhance the vasodilating effect of nitrates, which can cause profound hypotension. Patients should always be asked about these drugs before nitrates are given.
答案: B · In the first 15 minutes
Acute hemolytic and anaphylactic reactions usually appear early, so the transfusion is started slowly and the nurse stays with the patient for about the first 15 minutes, checking vital signs before, during and after according to policy.
答案: D · Test for HCV RNA to find out whether infection is current
Anti-HCV shows exposure, but some people clear the virus and keep antibodies. An HCV RNA test shows whether the infection is current. There is no vaccine for hepatitis C, but antiviral treatment can cure most infections.核对依据: Hepatitis C · MedlinePlus (NIH) (2025)
答案: A · Blood pressure of 160/105 mmHg
Ergot alkaloids cause vasoconstriction and can raise blood pressure sharply. They are contraindicated in hypertension and pre-eclampsia.
答案: B · Reliable contraception and pregnancy tests, as it is highly teratogenic
Isotretinoin causes severe birth defects. Pregnancy prevention programmes require effective contraception and regular pregnancy tests before, during and after treatment.
答案: D · 仅当 SpO₂ 低于目标范围时
对没有低氧血症的患者常规给予高流量氧气没有益处,还可能增大梗死面积。当饱和度低于目标值(例如某些指南为低于 90%,另一些为低于 94%)时才给氧。
答案: B · 根据出血风险和肾功能,暂停用药一段设定的时间
由于 DOAC 在数天内失效,通常根据手术的出血风险和肾功能,在术前暂停一段规定的时间(常为 1–3 天);一般不需要肝素桥接。维生素 K 不能逆转 DOAC。
答案: C · It can be raised by benign problems as well as by cancer
PSA can rise with BPH, prostatitis, UTI, recent ejaculation or instrumentation, as well as cancer. A normal level does not exclude cancer. Results are interpreted with symptoms, examination and other tests.
答案: B · "If she is unconscious, I will pour juice into her mouth."
An unconscious person cannot swallow safely, so fluids in the mouth can be aspirated. The family should put the person in the recovery position, give glucagon if trained and call for help. Once awake and able to swallow, the person eats a longer-acting carbohydrate.
答案: C · Modified-release tablets should not be crushed
Crushing modified-release or enteric-coated tablets can cause toxicity or loss of effect. Liquid forms are preferred; each medicine is given separately with flushes, and a pharmacist advises.
答案: A · 吗啡的代谢产物会蓄积,因此可能需要较低剂量或换用其他阿片类药物
吗啡的活性代谢产物(如吗啡-6-葡萄糖醛酸苷)经肾脏排泄,在肾功能受损时蓄积,引起镇静和呼吸抑制。可在密切监测下使用较低剂量、较长间隔或替代的阿片类药物。高龄会增加敏感性。
答案: D · Chemical, thermal, mechanical and sensory cues
Falling oxygen and rising carbon dioxide (chemical), cooler air (thermal), recoil of the chest after the birth canal (mechanical) and touch, light and sound (sensory) trigger the first breaths.
答案: B · Check for bladder distension and empty the bladder
Epidurals block bladder sensation, so the bladder can overfill. A full bladder can slow descent of the fetus and cause injury. The nurse should encourage voiding or catheterise per protocol.
答案: D · Inject into the outer thigh, through clothing if needed, and call emergency services
Auto-injectors are given into the outer mid-thigh and can go through clothing. Emergency services are called after every use, as symptoms can recur, and a second dose may be needed.
答案: B · He has not yet developed conservation, which is typical of the preoperational stage
Preoperational children focus on one feature, such as height, and cannot yet understand that the amount stays the same when the shape changes. Conservation develops in the concrete operational stage, from about 7 years.
答案: A · It is a partial agonist at dopamine D2 receptors
As a partial agonist, aripiprazole lowers dopamine activity where it is high and supports it where it is low. It is less likely to raise prolactin or cause sedation, but akathisia is a common side effect.
答案: B · Treatment without consent is lawful only under the conditions and procedures set by the law
Mental health laws allow some treatments for mental disorder without consent in defined circumstances, with safeguards such as second opinions and time limits. Staff must follow these procedures and record them, and should continue to seek the patient's agreement.
答案: 12:00 AM
24 小时制:下午 1 点起,小时数加 12(下午 3:45 = 15:45)。午夜到凌晨 12:59 为 00:00–00:59,中午 12:00–12:59 仍为 12:00–12:59。反过来换算时,13–23 点减 12 并标为下午;00 点变为凌晨 12 点。跨午夜计算时间要分两段:先算到 24:00(00:00),再从 00:00 算起。
答案: V = 300 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 = 500 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 = 5 mL
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 = 100 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。
答案: t = 10 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 = 20 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 = 6.6 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。
答案: B = 90 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 = 8.7 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 8 h 40 min,所以袋子大约在 02:40 输完。
答案: MFS = 75
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: 肥胖 II 级
体质指数:BMI = 体重(kg)/身高(m)²,身高要先换算为米。使用磅和英寸时,BMI = 703 × 体重(lb)/身高(in)²。WHO 成人分类:低于 18.5 为体重过轻,18.5–24.9 为健康体重,25.0–29.9 为超重,30.0–34.9 为肥胖 I 级,35.0–39.9 为肥胖 II 级,40 及以上为肥胖 III 级。
答案: 部分代偿
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。
答案: 慢性基础上的急性
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: 心脏停搏
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。
平直线必须核实:查看患者、导联和增益,并换看第二个导联,因为电极脱落或细颤型室颤都可能看起来像心脏停搏。
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