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 of these is recorded as fluid intake on a fluid balance chart?
At the start of a shift, which task should the nurse do first?
A patient with a fentanyl skin patch wants to use a heating pad on the area. What should the nurse teach?
一名夜班护士建议约束一位平静但会四处游走的患者,“这样今晚我们人手少也能应付”。下列哪种回应是正确的?
A malnourished patient admitted with alcohol use disorder needs IV glucose. Which vitamin is given before or with it?
A medical-unit nurse is floated to intensive care and given a patient on a ventilator, which the nurse has never managed. What is the best response?
一名患者新出现意识混乱,呼吸频率 24 次/分,收缩压 95 mmHg。你首先应怀疑什么?
一名颅脑损伤患者的 GCS 从 14 分降至 10 分,一侧瞳孔变大且对光反应迟钝。护士应该怎么做?
Why is a baseline platelet count taken before starting heparin therapy?
The nurse prepares a patient for a 2-hour oral glucose tolerance test tomorrow morning. Which statement shows a need for further teaching?
Which assessment is most important during IV mannitol therapy?
An older patient who has taken omeprazole for many years has muscle cramps, tremor and an irregular heartbeat. Which lab finding is most likely linked to the drug?
哪个肺炎严重程度评分使用意识混乱、尿素、呼吸频率、血压和年龄?
A nurse teaches a patient how to measure blood pressure at home. Which statement shows a need for further teaching?
腹膜透析液使用前应如何加温?
一名使用呼吸机的患者有创伤性脑损伤。除非即将发生脑疝,通常的 PaCO₂ 目标是什么?
A patient with obstructive sleep apnoea is admitted for surgery. Which instruction is most appropriate?
On the morning of elective hip surgery, a patient says she took her usual warfarin last night despite being told to stop. What should the nurse do?
A woman with hyperemesis gravidarum has been vomiting for weeks. Which vitamin is given before glucose-containing fluids to prevent Wernicke encephalopathy?
A woman on day 2 after a caesarean suddenly has chest pain, breathlessness, a heart rate of 120/min and an oxygen saturation of 90%. What is the priority?
After a cardiac catheterisation through the femoral artery, which assessment is essential?
A child with Hirschsprung disease awaiting surgery develops fever, explosive diarrhoea and a very swollen abdomen. What should the nurse suspect?
Which US legal case is associated with the duty of mental health professionals to protect people who are threatened by a patient?
On a mental health ward, which task is most appropriate for the nurse to delegate to a healthcare assistant?
练习题(虚构数值,不作为临床指导)。 一名新生儿体重 8 lb 10 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)。 血糖结果为 260 mg/dL。按葡萄糖 1 mmol/L = 18 mg/dL,求以 mmol/L 表示的c。取到一位小数。
一名体重 100 kg 的患者体表面积为 1.88 m²。医嘱为 50 mg/m²。求剂量 D,以 mg 表示。
处方剂量为 1.1 mg。安瓿每 mL 含 2000 微克。请用 1 mL 注射器抽取剂量:应给多少体积 V?
用滴系数为 15 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 50 mL 中含药 100 mg,以 8 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 2 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 800 mg,容量 500 mL。医嘱为 6 mcg/kg/min,患者体重 74 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。患者体重 88 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)。 一袋 1000 mL 的液体于 09:30 开始用输液泵以 125 mL/h 输注。到 14:30 时袋中还剩多少 mL V?
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 26 次/分,SpO₂ 97%正在补充吸氧,血压 84/50 mmHg,脉搏 130 次/分,清醒,体温 38.1 °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 7 次/分,SpO₂ 99%吸室内空气,血压 112/68 mmHg,脉搏 58 次/分,清醒,体温 37.3 °C。患者属于哪个临床风险组?点击它。
某练习血气显示 PaCO₂ 51 mmHg (6.8 kPa)。利用规则:在慢性呼吸性酸中毒中,PaCO₂ 每比 40 高出 10 mmHg,HCO₃⁻ 升高 3.5 mmol/L,以HCO₃⁻ 24 mmol/L 为起点,求预期HCO₃⁻。
某练习血气显示代谢性碱中毒,HCO₃⁻ 39 mmol/L。用预期 PaCO₂ = 0.7·HCO₃⁻ + 21 求预期PaCO₂。
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 · Intravenous fluids
Intake includes oral fluids, enteral feeds and IV fluids, including drug infusions. Urine, vomit, drainage and stool are output.
答案: B · Give the first IV antibiotic dose to a patient with suspected sepsis
In sepsis antibiotics are time-critical, and every hour of delay increases the risk of death. Routine tasks are done afterwards.
答案: A · Avoid heat on or near the patch, because it increases how fast the drug is absorbed
Heat from heating pads, electric blankets, hot tubs or fever increases fentanyl absorption and can cause an overdose. Patients are taught to avoid heat over the patch.
答案: A · 约束绝不能为方便工作人员;应采用巡视或陪护
只有在限制性较小的措施无效、需要保护患者或他人免受即时伤害时才允许使用约束,绝不能出于方便或惩戒。巡视、床报警器、陪护和安静的环境都是替代办法。
答案: B · 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: B · Tell the charge nurse about the gap, accept tasks within competence and ask for support
A nurse should clearly state the limits of their competence and ask for an assignment or support that keeps patients safe. Leaving without handover would be patient abandonment.
答案: A · 脓毒症
这三项体征构成 qSOFA 标准,提示脓毒症预后不良的风险很高。应紧急上报并启动脓毒症处理流程。
答案: B · 作为神经科急症立即上报
GCS 下降伴单侧瞳孔散大提示颅内压升高、可能发生脑疝。需要紧急医疗评估和影像学检查。
答案: C · So a later fall from heparin-induced thrombocytopenia is detected
Heparin-induced thrombocytopenia is diagnosed partly by a fall of about 50% or more from the baseline count, usually 5–14 days after starting. A baseline count and regular checks make this possible.核对依据: Heparin-Induced Thrombocytopenia · StatPearls (NCBI Bookshelf) (2023)
答案: B · "I can have a light breakfast before the test"
The OGTT is done after an overnight fast of at least 8 hours; water is allowed. Eating before the test makes the results invalid. Patients rest during the test and avoid smoking, which can affect glucose.核对依据: Blood Glucose Test · MedlinePlus (NIH) (2024); Glucose tolerance test - non-pregnant · MedlinePlus (NIH) (2025)
答案: B · Urine output, electrolytes and signs of fluid overload
Mannitol draws fluid into the circulation before it is excreted, which can cause heart failure and pulmonary oedema. The large diuresis can cause dehydration and electrolyte imbalance, so output and electrolytes are monitored.
答案: A · Low serum magnesium
Long-term PPI use can cause hypomagnesaemia, which leads to cramps, tremor and arrhythmias. Other long-term risks include fractures, vitamin B12 deficiency and C. difficile infection.
答案: D · CURB-65
CURB-65 对以下各项各计一分:意识混乱(Confusion)、尿素 >7 mmol/L(Urea)、呼吸频率 ≥30 次/分(Respiratory rate)、低血压(Blood pressure,收缩压 <90 或舒张压 ≤60 mmHg)以及年龄 ≥65 岁。分数越高,死亡率越高,需要住院或重症监护。
答案: D · "I will measure it straight after my morning jog."
Home readings should be taken after resting quietly for about 5 minutes, sitting with back supported, feet flat and the arm supported at heart level, with no recent exercise, caffeine or smoking. Two readings are often recorded. Measuring after exercise gives falsely high results.
答案: D · 在专用的干热加温器中
将透析液加温至体温可提高舒适度。微波炉加热不均匀,会产生热点;浸泡可能污染接口。应使用制造商认可的干热加温器。
答案: C · 正常的 PaCO₂(正常碳酸血症)
高 CO₂ 使脑血管扩张并升高颅内压,而过度通气使其收缩,可引起脑缺血。通常以正常碳酸血症(约 4.7–5.3 kPa,即 35–40 mmHg)为目标;仅在出现即将脑疝的征象时短暂过度通气,作为确定性治疗前的过渡。
答案: B · Bring their CPAP machine to use after surgery
OSA increases the risk of airway obstruction and respiratory depression after anaesthesia, especially with opioids. Using CPAP, careful opioid use, sitting up and close monitoring reduce this risk.
答案: A · Inform the surgical and anaesthetic teams, who will check the INR
Recent warfarin may leave the INR too high for safe surgery or a spinal anaesthetic. The team needs to know at once; they check the INR and decide whether to delay or reverse.
答案: D · Thiamine (vitamin B1)
Prolonged vomiting depletes thiamine. Giving glucose without thiamine can trigger Wernicke encephalopathy, with confusion, ataxia and eye movement problems.
答案: C · Call for help, sit her up and give oxygen
Sudden breathlessness, chest pain, tachycardia and hypoxia suggest pulmonary embolism, a leading cause of maternal death. The nurse calls for urgent help, positions her upright, gives oxygen and prepares for investigations and anticoagulation.
答案: A · Pulse, colour, warmth and sensation of the leg below the puncture site
After catheterisation, the nurse checks the puncture site for bleeding and the affected leg for pulses, colour, temperature and sensation to detect clotting or bleeding. The leg is kept straight for the time set by local policy.
答案: A · Enterocolitis, an emergency
Hirschsprung-associated enterocolitis is a life-threatening complication with fever, explosive foul-smelling diarrhoea and distension. It can progress to sepsis and needs urgent medical treatment.
答案: D · Tarasoff v Regents of the University of California
In Tarasoff (California, 1976), the court held that therapists have a duty to take reasonable steps to protect an identifiable person from a serious threat made by a patient. Similar principles exist in many jurisdictions.
答案: C · Accompanying a stable patient to the dining room and recording his food intake
Routine, predictable tasks with stable patients, such as escorting and recording intake, can be delegated. Assessment, care planning, teaching and evaluation require the nurse's judgement.
答案: m = 3.92 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: c = 14.4 mmol/L
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 = 94 mg
Body-surface-area dosing: many cytotoxic and some paediatric doses are prescribed per square metre of body surface area: dose (mg) = dose per m² × BSA (m²). The Mosteller formula estimates BSA = √(height (cm) × weight (kg)/3600).
答案: V = 0.55 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 = 63 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:63 滴/分。
答案: D = 16 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 = 2 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 = 16.7 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: U = 1.35 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: V = 375 mL
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。
答案: NEWS2 = 11
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: 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: HCO₃⁻ = 27.85 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: PaCO₂ = 48.3 mmHg
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。
升高是有限度的:仅靠代偿,PaCO₂ 很少超过约 55 mmHg。
答案: 室上性心动过速(SVT)
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。 窄 QRS 心动过速与停顿:室上性心动过速(SVT)是规则的心动过速,约 150–250 次/分钟,QRS 波群较窄;P 波通常看不到,因为它们隐藏在 QRS 波群或 T 波中。成人静息时的窦性心动过速通常低于约 150 次/分钟,且每个 QRS 前都有可见的 P 波;伴 2:1 传导的心房扑动常在约 150 次/分钟,并显示锯齿波。窦性停搏是指窦房结暂时停止发放冲动:出现既无 P 波也无 QRS 的停顿,其长度不是 P–P 周期的整数倍(恰好两个或三个周期的停顿则提示窦房传导阻滞)。
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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