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。
How should a nurse speak to a patient with hearing loss?
In English law, giving a treatment to a competent adult who has clearly refused it may amount to:
A patient with a severe latex allergy is booked for surgery. Which measure is commonly used?
A nurse teaches a patient about care of a surgical incision at home. Which statement shows a need for further teaching?
A patient with a spinal cord injury at T4 suddenly has a severe headache, flushing above the injury and a blood pressure of 200/110 mmHg. What does the nurse do first?
哪项委派适合护理助理?
After a laparoscopic cholecystectomy, a patient has pain in the shoulder tip. What is the most likely cause?
开始输血后不久,患者出现气短、喘鸣、低血压和面部肿胀。护士首先应该做什么?
A patient taking spironolactone asks about using a salt substitute. What should the nurse explain?
一份 aPTT 结果极高,但护士得知样本是从输注肝素的那只手臂采集的。最好的措施是什么?
SSRI 与哪种药物合用最会增加 5-羟色胺综合征的风险?
A patient with myasthenia gravis took extra pyridostigmine doses. She now has increasing weakness, heavy salivation, sweating, small pupils and diarrhoea. What is the most likely cause?
Why is a shock for cardioversion synchronised with the QRS complex?
经桡动脉心导管检查术后,最重要的评估是什么?
A patient taking warfarin is diagnosed with an intracerebral haemorrhage. What is the priority treatment?
A patient with renal colic has normal kidney function and no other contraindications. Which drug is usually the first choice for pain?
哪些床旁评估用于追踪腹水?
A nurse teaches a patient with GORD. Which statement shows a need for further teaching?
A pregnant woman taking iron says her stools have turned black. What is the best response?
At 4 hours, a newborn's temperature is 37.9 °C (100.2 °F). He is wrapped in three blankets under a heater. What should the nurse do first?
A toddler refuses a liquid medicine. Which approach is appropriate?
一个家庭坚持在孩子接受疼痛性操作时留在身边。在以家庭为中心的护理中,最恰当的回应是什么?
Shortly after a sexual assault, a woman in the emergency department is calm, quiet and answers questions in a flat voice. How should the nurse interpret this?
A patient with alcohol dependence is confused, unsteady on his feet and has abnormal eye movements. Why is it urgent to give thiamine?
练习题(虚构数值,不作为临床指导)。 一次注射的剂量计算得到 11.4752 mL。 本练习的规则是:1 mL 或以上的体积取到最接近的十分之一 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)。 一张处方写着口服混悬液1½ tsp,每 8 小时一次,共 14 天。按1 tsp = 5 mL,整个疗程需要多少 mLV?
某患者体重 60 kg,医嘱为单次给药 10 mg/kg。求剂量 D(mg)。
一名体重 12 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? 保留一位小数。
滴注以 20 gtt/min 的速度通过滴系数为 15 gtt/mL 的输液器。患者在 12 小时内接受多少毫升 V?
一组输液以 32 滴/分的速度经 20 滴/mL 的输液器滴注。袋中还剩 400 mL。还需多少小时 t 才会滴完? 保留一位小数。
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 16 units/kg/h,患者体重 55 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 75 kg 的患者的医嘱为nitroglycerin 5 mcg/min。输液袋中含 50 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。患者体重 86 kg。求平均尿量 U,以 mL/kg/h 计。 保留两位小数。
练习题(虚构数值,不作为临床指导)。 一份 1000 mL 的输液于 15:00 开始以 120 mL/h 输注。4 小时后速率改为 125 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)。 一位患者的脉搏为 60 次/分,血压为 93/60 mmHg。求休克指数SI = HR/SBP。取到两位小数。
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 18 次/分,SpO₂ 90%正在补充吸氧,血压 100/60 mmHg,脉搏 88 次/分,清醒,体温 36.3 °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 7.61,PaCO₂ 25 mmHg (3.3 kPa),HCO₃⁻ 24 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。
某练习血气显示代谢性酸中毒:pH 7.26,PaCO₂ 23 mmHg (3.1 kPa),HCO₃⁻ 10 mmol/L。把实测的PaCO₂与温特公式比较。点选你的解读。
解读这条 II 导联心律条带。这是什么节律?点击你的答案。
这位患者装有起搏器。请解读这条 II 导联心电图条带。点击你的答案。
答案: D · Face the patient and speak clearly at a normal pace
Facing the patient in good light, reducing background noise and speaking clearly, without shouting, helps understanding. Hearing aids should be in and working.
答案: B · Battery (trespass to the person)
Touching or treating a person without valid consent can be battery, even if the treatment was meant to help. This is why consent is needed before care.
答案: C · Use latex-free supplies and schedule the patient as the first case of the day
Latex proteins can become airborne on glove powder and settle in the room. Using a latex-safe room and supplies and scheduling the patient first, when airborne latex is lowest, reduce the risk.
答案: C · “If the wound gets red and drains pus, I will wait for my appointment next month.”
Increasing redness, purulent drainage, fever and worsening pain are signs of surgical site infection and should be reported promptly. Waiting a month could allow the infection to spread.
答案: A · Sit the patient upright with the legs lowered
Autonomic dysreflexia is an emergency in injuries at T6 or above. Sitting the patient up lowers the blood pressure; the nurse then looks for the trigger, most often a full bladder or constipation.
答案: D · 为稳定的患者采集常规尿标本
为稳定的患者采集常规尿标本是可预测、可委派的。确认管道位置、吞咽筛查前喂食以及监测输血开始阶段都需要护理评估。
答案: B · Gas used during the operation irritating the diaphragm
Carbon dioxide used to inflate the abdomen can irritate the diaphragm, causing referred shoulder-tip pain. It usually settles within a few days with mobilisation and analgesia.
答案: A · 停止输血,保留静脉通路,并紧急呼救
严重输血反应(包括过敏性休克)需要立即停止输血,保留静脉通路,按 ABCDE 方法处理,并用肌注肾上腺素治疗过敏性休克。
答案: D · Most salt substitutes contain potassium and can raise the level too high
Spironolactone blocks aldosterone, so the kidneys keep potassium. Many salt substitutes are made of potassium chloride, and combining them with spironolactone can cause dangerous hyperkalemia, especially with kidney disease or ACE inhibitors.核对依据: Spironolactone · MedlinePlus (NIH) (2018); High potassium level · MedlinePlus (NIH) (2025)
答案: B · 在调整剂量之前,要求从对侧手臂重新采样
从输液手臂抽取的血液含有来自输液的肝素,因此 aPTT 假性偏高。来自另一只手臂的样本才能给出真实的结果。根据错误的结果改变剂量可能导致血栓形成。核对依据: Partial Thromboplastin Time (PTT) Test · MedlinePlus (NIH) (2026)
答案: C · 单胺氧化酶抑制剂
SSRI 阻断 5-羟色胺再摄取,MAO 抑制剂阻断其分解。两者合用可引起 5-羟色胺综合征,表现为激越、高热、震颤和阵挛。
答案: C · Cholinergic crisis from too much anticholinesterase drug
Excess acetylcholine causes muscarinic signs (salivation, sweating, miosis, diarrhoea) and depolarising weakness. In myasthenic crisis, weakness occurs without these cholinergic signs; both can cause respiratory failure.
答案: B · To avoid delivering the shock during the T wave
A shock delivered on the T wave (the vulnerable period) can trigger ventricular fibrillation. Synchronisation times the shock to the R wave. In ventricular fibrillation there is no organised QRS, so defibrillation is unsynchronised.
答案: A · 手部的血液循环、感觉和活动,以及穿刺部位
桡动脉入路后,应检查压迫装置和穿刺部位有无出血或血肿,并检查手部的颜色、温度、毛细血管再充盈、感觉和活动。桡动脉闭塞和前臂骨筋膜室综合征是可能的并发症。
答案: A · Urgent reversal of the anticoagulant effect
Anticoagulants make the haematoma expand. Warfarin is reversed urgently, typically with prothrombin complex concentrate and IV vitamin K. Thrombolysis and antiplatelets are contraindicated in a bleed.
答案: A · An NSAID such as diclofenac
NSAIDs are recommended first line for renal colic in suitable patients because they reduce prostaglandin-driven pain and ureteric spasm. Opioids are added if needed. NSAIDs are avoided in kidney impairment.
答案: B · 每日体重和腹围
每日体重和在同一标记水平测量的腹围可显示腹水是在增加还是减少。还应监测液体平衡、肾功能和电解质,尤其是在使用利尿剂时。
答案: C · "Peppermint tea after dinner will settle my reflux."
Peppermint can relax the lower oesophageal sphincter and may worsen reflux. Weight loss, stopping smoking and avoiding personal triggers are standard lifestyle measures.
答案: C · Explain that this is an expected effect of iron
Iron supplements commonly make stools dark green or black. This is harmless, unlike tarry stools with signs of bleeding such as dizziness.
答案: D · Remove extra layers and recheck
Overheating from heavy wrapping or a heater can raise a newborn's temperature. The nurse removes extra layers, rechecks the temperature soon and assesses for signs of infection if it stays high.
答案: D · Mix it with a small spoonful of food, if the pharmacist says this is safe
Mixing with a small amount of food that will be eaten completely, when the medicine allows it, helps the child take the full dose. Large volumes may not be finished, calling medicine sweets is unsafe and forcing risks aspiration.
答案: B · 支持他们在场,为他们将看到的情况做好准备,并赋予他们安抚的角色
以家庭为中心的护理支持家属在操作期间在场。应为父母做好准备,赋予他们一个角色,如抱着或分散孩子的注意力,并让他们自己选择是否留下。
答案: D · A controlled response is a common reaction in the acute phase after assault
In the acute phase of rape trauma syndrome, survivors may show an expressive reaction, such as crying or anger, or a controlled one, appearing calm or numb. Both are normal responses and need the same support.
答案: C · Wernicke's encephalopathy can be reversed if treated early, but may otherwise lead to permanent Korsakoff syndrome
Wernicke's encephalopathy is an emergency caused by thiamine deficiency. Prompt high-dose thiamine can reverse it, but delay can lead to Korsakoff syndrome with lasting memory loss, or death.
答案: x = 11.5 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 = 315 mL
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: D = 600 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 = 3.8 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: V = 960 mL
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
答案: t = 4.2 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 = 22 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 = 1.5 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: U = 1.42 mL/kg/h
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 = 8.2 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 10 min,所以袋子大约在 23:10 输完。
答案: SI = 0.65
血压数值:脉压 PP = SBP − DBP。平均动脉压 MAP ≈ (SBP + 2·DBP)/3 = DBP + PP/3,这是基于正常心率下心脏每搏约有三分之二时间处于舒张期的估算(心率快时准确性下降);MAP 至少约 65 mmHg 是常用的器官灌注目标。休克指数 SI = 心率/SBP,正常约为 0.5–0.7;高于约 1 是休克的警示信号。
在通常的 0.5–0.7 之内或之下。
答案: 高
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。
总分 5 或以上需要紧急的临床响应。
答案: 未代偿
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: 适当的代偿
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: 正常窦性心律
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: 心室起搏心律
起搏心律:起搏器脉冲表现为一条细而垂直的起搏钉样信号。心室钉样信号之后的 QRS 是增宽的(0.12 s 或以上),因为冲动是从导线经心肌传播,而不是经传导系统;右心室起搏时,在 II 导联上通常以负向为主。P 波之前的钉样信号表示心房起搏;双腔(房室)起搏器则表现为心房钉样信号加 P 波,再经过程控的房室延迟,出现心室钉样信号和增宽的 QRS。夺获是指每个钉样信号之后都跟着一次除极。夺获失败是指钉样信号之后没有 P 波或 QRS;感知不良(钉样信号无视患者自己的心搏)和起搏不良(该出现钉样信号时没有)是另外两种典型的故障。
起搏产生的 QRS 本来就是增宽的;不要称它为束支传导阻滞或室性心律。
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