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。
When are non-sterile gloves needed?
According to the gate control theory, why can rubbing a bumped elbow ease the pain?
Before helping a patient from bed into a wheelchair, what should the nurse do with the wheelchair?
A nurse finds that a patient has been taking their own sleeping pills from a bedside drawer while also receiving a hypnotic from the ward. What should the nurse do?
During labor, the nurse sees the umbilical cord in the vagina after the membranes rupture. What is the first action?
During birth, the baby’s head delivers but the shoulders do not follow. What should the nurse do first?
Which measure helps reduce the risk of surgical site infection?
Why can pulse oximetry be misleading in carbon monoxide poisoning?
A patient has a calcium of 11.8 mg/dL (2.95 mmol/L) from bone metastases. Which nursing measure is appropriate?
哪种结果模式符合 SIADH?
How is adenosine given for supraventricular tachycardia?
In myxoedema coma, why is hydrocortisone often given before or with thyroid hormone?
A patient with an implantable cardioverter-defibrillator asks what to do if it fires. Which teaching is correct?
Three days after an MI, a patient faints on the commode while straining hard to open the bowels. The heart rate was 42/min at the time. What is the most likely mechanism?
为什么脊髓损伤后常教患者间歇性自我导尿?
A patient with a brain tumour on high-dose dexamethasone has a capillary glucose of 16 mmol/L (288 mg/dL). They have no history of diabetes. What is the best explanation?
Which is correct when caring for a patient with a PICC line?
急性胰腺炎最初几小时,通常推荐哪种补液策略?
一名对风疹无免疫力的产妇在出院前接种疫苗。必须给予哪项建议?
产程中胎膜刚破裂,一名女性突然变得非常气促、发绀和低血压。应怀疑哪种情况?
A child has tinea capitis (ringworm of the scalp). Which treatment is usually needed?
A 3-year-old was pulled from a pool after a brief submersion. She is now awake and coughs now and then. What should the nurse advise?
Flumazenil reverses benzodiazepine sedation. Why is it used with caution in patients who take benzodiazepines long-term?
一名服用舍曲林的患者因疼痛被给予曲马多。数小时后,他激越、出汗、震颤,踝部出现阵挛。最可能的问题是什么?
练习题(虚构数值,不作为临床指导)。 一名新生儿体重 7 lb 9 oz。按 1 lb = 16 oz 和 1 kg = 2.2 lb,求以千克表示的体重m。取到两位小数。
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½ tsp,每天两次,共 7 天。按1 tsp = 5 mL,整个疗程需要多少 mLV?
需要从 1%(w/v)溶液中取 20 mg 的剂量。多少容量 V 含有这一剂量?
处方剂量为 1180 微克。安瓿浓度为 2 mg/mL。请用 1 mL 注射器抽取剂量:应给多少体积 V?
医嘱要求以 60 mL/h 输液,但没有输液泵。改用滴系数为 60 gtt/mL 的输液器重力滴注。求滴速 R,以每分钟滴数表示。
25 mg 药物溶于 250 mL 的输液以 6 mL/h 运行。患者每分钟接受多少微克 D?
练习题(虚构数值,不作为临床指导)。 一项练习规程要求为体重 54 kg 的患者推注肝素 70 units/kg。药瓶规格为 5 000 units/mL。应抽取多少体积 V? 保留两位小数。
练习题(虚构数值,不作为临床指导)。 一名体重 59 kg 的患者的医嘱为nitroglycerin 20 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 500 mL 的输液于 16:30 开始以 125 mL/h 输注。3 小时后速率改为 75 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)。 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: 无、卧床休息或由护士协助; 静脉输液或封管: 否; 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)。 对这些观察结果使用 NEWS2 图表(SpO₂ 量表 1):呼吸频率 18 次/分,SpO₂ 86%吸室内空气,血压 112/68 mmHg,脉搏 70 次/分,清醒,体温 37.1 °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 32 mmHg (4.3 kPa),HCO₃⁻ 18 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。
某练习血气显示 pH 7.25,PaCO₂ 21 mmHg (2.8 kPa),HCO₃⁻ 9 mmol/L,Na⁺ 146,Cl⁻ 107 mmol/L。利用阴离子间隙和 Δ 比值,点选最合适的解读。
这条 II 导联心电图显示心房扑动。测量扑动波间期,求出心房率(单位:次/分)。
识别这条 II 导联心电图上的节律。点击你的答案。
答案: D · When contact with blood, body fluids or broken skin is expected
Under standard precautions, gloves are worn when exposure to blood or body fluids is likely. Wearing them for all contact gives false security and can spread germs if not changed.
答案: C · Touch signals reduce pain signals passing up the spinal cord
The gate control theory proposes that input from touch fibres "closes the gate" in the dorsal horn of the spinal cord, reducing pain transmission. This underlies massage and TENS.
答案: C · Lock the brakes and place it close to the bed on the patient’s stronger side
Locked brakes stop the chair rolling away during the transfer. Placing it close to the bed on the stronger side lets the patient lead with their strong leg.
答案: D · Secure the home medication per policy and inform the provider
Unrecorded home medicines can lead to duplicate doses, interactions and falls. They are stored or sent home according to policy, and the provider is told so the treatment plan can be reviewed.
答案: D · Relieve pressure on the cord by lifting the presenting part with a gloved hand
In cord prolapse, the presenting part can compress the cord and cut off fetal oxygen. The nurse lifts the presenting part off the cord, calls for help and positions the patient (for example knee-chest) while urgent birth is arranged.
答案: A · Help with the McRoberts position and give suprapubic pressure as directed
In shoulder dystocia, the McRoberts maneuver (flexing the mother’s thighs onto her abdomen) and suprapubic pressure help free the shoulder. Fundal pressure and pulling on the head can worsen the injury.
答案: C · Removing hair, if needed, with clippers rather than a razor
Razors cause micro-abrasions that increase infection risk, so hair is removed only if necessary with clippers just before surgery. Keeping patients warm and good skin preparation also help.
答案: B · Standard oximeters cannot tell carboxyhaemoglobin from oxyhaemoglobin
Standard SpO2 can appear normal despite severe tissue hypoxia. Carboxyhaemoglobin is measured on a blood gas, and high-concentration oxygen is given.
答案: B · Encourage fluids and mobility as tolerated
Hydration helps the kidneys excrete calcium and prevents stones, and weight-bearing mobility slows calcium loss from bone. Calcium-containing foods and antacids are not encouraged. The nurse also monitors for confusion, constipation and arrhythmias.核对依据: Hypercalcemia · MedlinePlus (NIH) (2026)
答案: A · 血清钠低、血清渗透压低、尿液浓缩
抗利尿激素过多导致水潴留,稀释血液(钠和渗透压低),而尿液反常地浓缩。钠高伴尿液非常稀是尿崩症的模式。核对依据: Syndrome of inappropriate antidiuretic hormone secretion · MedlinePlus (NIH) (2025)
答案: B · As a rapid IV push followed by a fast saline flush
Adenosine must reach the heart quickly, so it is pushed rapidly into a large vein and flushed. Patients are warned about brief flushing, chest tightness and a short pause in the heartbeat.
答案: D · Thyroid hormone can trigger adrenal crisis if cortisol is also low
Restoring thyroid hormone increases metabolic rate and cortisol clearance. If adrenal reserve is also low, this can precipitate adrenal crisis, so steroid cover is given until adrenal insufficiency is excluded.
答案: C · One shock and well: contact the device clinic; repeated shocks or unwell: call emergency services
A single shock with full recovery usually needs a call to the device team. Several shocks in a short time, or a shock with chest pain, breathlessness or collapse, needs emergency help. Patients should not drive themselves after a shock.
答案: B · A vagal response to straining
Straining (the Valsalva manoeuvre) can cause a vagal bradycardia and a fall in cardiac output, leading to syncope. After an MI, stool softeners, adequate fluids and avoiding straining are advised. The event is still reported and the patient assessed for arrhythmia or ischaemia.
答案: D · 膀胱可能无法排空,定期排空可保护肾脏
脊髓损伤常引起神经源性膀胱。定期清洁间歇导尿可排空膀胱,防止高压,减少感染和肾损伤,并避免诱发自主神经反射异常。
答案: B · Steroid-induced hyperglycaemia, which needs monitoring and treatment
Glucocorticoids increase glucose production and insulin resistance, so hyperglycaemia is common, often later in the day after a morning dose. Glucose is monitored regularly, and treatment may be needed. Other steroid effects include mood change and gastric irritation.
答案: A · Avoid taking blood pressure on the arm with the line
BP cuffs and tourniquets on the PICC arm can damage the line. The external length and site are checked, the dressing is kept intact, and the line is flushed and used with aseptic technique according to policy.
答案: C · 以目标为导向的平衡晶体液,根据反应调整
胰腺炎使液体丢失到组织中,所以早期静脉补液很重要。最新指南倾向于使用哈特曼液或乳酸林格液等平衡晶体液进行适度、以目标为导向的复苏,并根据心率、血压和尿量调整,因为过于积极的补液只会增加负荷而没有益处。
答案: B · 至少 4 周内避免怀孕
风疹疫苗含有减毒活病毒,因此接种后至少 4 周内应避免怀孕。它与母乳喂养并不冲突。
答案: D · 羊水栓塞
羊水栓塞引起突发呼吸困难、缺氧、低血压,并常因凝血功能障碍而出血。这是急症:呼叫急救团队,并根据需要开始复苏。
答案: D · An oral antifungal medicine
Topical creams cannot reach the fungus in the hair shafts and follicles, so tinea capitis needs an oral antifungal for several weeks, sometimes with an antifungal shampoo to reduce spread.
答案: A · Observe her in hospital for several hours, as breathing problems can develop later
After a drowning incident, even a child who seems well can develop worsening breathing difficulty and low oxygen over the following hours. Children who had symptoms such as coughing need medical assessment and a period of observation.
答案: C · It can cause sudden withdrawal and seizures
Flumazenil is a benzodiazepine antagonist. In dependent patients, or in mixed overdoses with drugs that lower the seizure threshold, it can trigger acute withdrawal and seizures.
答案: A · 5-羟色胺综合征
曲马多具有 5-羟色胺能作用,与 SSRI 合用可引起 5-羟色胺综合征。应停用 5-羟色胺能药物并给予支持治疗;严重病例需要重症监护。
答案: m = 3.44 kg
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: V = 35 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: V = 2 mL
Solution strengths: a percentage strength is grams per 100 mL, so 1% = 1 g/100 mL = 10 mg/mL. A ratio strength 1:1000 means 1 g in 1000 mL = 1 mg/mL; 1:10 000 is 0.1 mg/mL. For a dilution the amount of drug stays the same: C₁·V₁ = C₂·V₂.
答案: V = 0.59 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。
答案: R = 60 gtt/min
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.
使用微滴输液器(60 gtt/mL)时,gtt/min 等于 mL/h。
答案: D = 10 mcg/min
Dose-based infusions: concentration = amount of drug in the bag/bag volume. Pump rate (mL/h) = dose per hour/concentration, and dose per hour = mL/h × concentration. Convert per-minute doses to per-hour (× 60) and keep the mass units the same (1 g = 1000 mg, 1 mg = 1000 mcg).
答案: V = 0.76 mL
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 = 12 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: I = 1750 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 = 4.7 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 4 h 40 min,所以袋子大约在 21:10 输完。
答案: MFS = 40
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: 中低
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。
即使总分低,单项得 3 分也需要紧急会诊。
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 33–37 mmHg,所以实测 32 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: 单纯高间隙酸中毒
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: 心房率 = 250 bpm
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: 室性心动过速
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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