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。
A patient says, "I've never seen this tablet before," as the nurse offers it. What should the nurse do?
A patient with COPD and a known risk of hypercapnia is acutely breathless with an SpO₂ of 82%. What is correct?
病房暴发诺如病毒感染期间,工作人员在护理患者后应采用哪种手卫生方法?
A patient’s allergy band says “penicillin”, and an order has been written for amoxicillin. What should the nurse do?
A patient with type 1 diabetes has vomited since morning and cannot eat. Which action is most important?
A child with sickle cell disease in a pain crisis develops chest pain, fever and an SpO₂ of 89%. What does this most likely mean?
Why are patients encouraged to use an incentive spirometer after abdominal surgery?
A patient with hyperkalaemia is given IV insulin with glucose. What is the purpose, and what must be monitored?
A patient has taken hydrochlorothiazide for several years. Which laboratory change is a recognized effect of this drug?
The nurse teaches a patient with iron-deficiency anemia who is starting oral iron. Which statement shows a need for further teaching?
服用老一代 MAO 抑制剂的患者被警告避免富含酪胺的食物。可能会发生什么?
A patient on digoxin is started on amiodarone. What change should the nurse expect?
一名近期卒中且吞咽困难的患者出现发热和右下肺湿啰音。最可能的原因是什么?
一名 82 岁的社区获得性肺炎患者新近出现意识混乱,呼吸频率 32 次/分,血压 88/52 mmHg,尿素 9 mmol/L。这提示什么?
A patient with a new ileal conduit has threads of mucus in their urine. What should the nurse explain?
卒中阿替普酶输注期间,患者出现剧烈头痛、呕吐和 GCS 下降。护士首先应做什么?
内镜检查前,哪个评分用于评估上消化道出血的风险?
A patient with a severe flare of ulcerative colitis develops abdominal distension, fever and tachycardia, and the stool frequency has dropped. What should the nurse suspect?
Which statement describes the "4 Ts" causes of postpartum haemorrhage?
A woman 2 hours after birth asks for help to the bathroom. She had an epidural that is now off. What is the main safety concern?
哪种来源是幼儿铅中毒的常见原因?
A 4-year-old chokes on a sweet but is coughing forcefully and can speak. What should the nurse do?
Which question is the best way to ask a patient about suicidal thoughts?
A patient who believes he is a famous religious leader becomes upset when other patients laugh at him. What is the most appropriate nursing action?
练习题(虚构数值,不作为临床指导)。 一名新生儿体重 5 lb 3 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)。 一次输注的给药速率为 2 mg/h。请把这个剂量速率D用 mcg/min 表示。取到一位小数。
某患者体重 60 kg。医嘱剂量为每天 2 mg/kg,分 3 次等量给药。每次给多少毫克 D?
一名患者体重 85.8 lb。医嘱为单次剂量 2 mg/kg,储备液为 5 mL 中含 125 mg。按 1 kg = 2.2 lb 计算,你应给予多少容量 V? 保留一位小数。
医嘱要求在 10 小时内输入 500 mL。3 小时后你发现袋中还剩 430 mL,而输液仍须按时完成。 必须把泵重新设定为多少 mL/h 的速率 R?
医嘱要求在 12 小时内输入 500 mL。6 小时后你发现袋中还剩 280 mL,而输液仍须按时完成。 原来的泵速必须提高百分之多少 Δ?
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 0.05 units/kg/h,患者体重 78 kg。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 250 mg,容量 250 mL。医嘱为 2.5 mcg/kg/min,患者体重 87 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 500 mL 的液体用输液泵以 75 mL/h 输注。到 13:00 时已输入 100 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: 否; 行走辅助: 扶着家具; 静脉输液或封管: 是; 步态: 虚弱; 精神状态: 高估或忘记自身局限。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 56 kg,身高 183 cm。计算 BMI 并点击 WHO 体重分类。
某练习动脉血气显示 pH 7.36,PaCO₂ 73 mmHg (9.7 kPa),HCO₃⁻ 40 mmol/L。原发性紊乱是呼吸性酸中毒。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 7.24,PaCO₂ 77 mmHg (10.3 kPa),HCO₃⁻ 32 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。
这条 II 导联心电图显示心房扑动。每个 QRS 波群对应多少个每个 QRS 对应的扑动波(n:1 传导中的 n)?
这条 II 导联心电图显示房室传导阻滞,心室节律不规则。使用 6 秒法求出心室率(单位:次/分)。
答案: D · Stop and recheck the prescription before giving it
A patient questioning a medicine may be a sign of an error. The nurse holds the dose, checks the prescription and the drug and explains before giving it.
答案: C · Give controlled oxygen, e.g. via a Venturi mask, aiming for 88–92%
Oxygen must not be withheld from a hypoxic patient. In those at risk of hypercapnia it is given in a controlled way to a target of 88–92%, with blood gases checked.
答案: B · 用肥皂和水洗手
酒精手消毒剂不能可靠地杀灭诺如病毒,所以应使用肥皂和水洗手,通过机械作用将其清除。同时还应采取接触传播预防和彻底的环境清洁。
答案: D · Hold the drug and contact the prescriber
Amoxicillin is a penicillin, so it could cause a serious allergic reaction. The nurse holds the drug, clarifies the allergy and contacts the prescriber for a safe alternative.
答案: A · Check the blood glucose and ketones and contact the provider
Vomiting in type 1 diabetes can lead quickly to diabetic ketoacidosis. Glucose and ketones are checked and the provider is contacted; insulin is usually not stopped completely during illness.
答案: B · Acute chest syndrome, which needs urgent escalation and oxygen
Chest pain, fever and low oxygen in sickle cell disease suggest acute chest syndrome. It can worsen quickly, so oxygen, urgent review and prescribed treatment are needed.
答案: C · To encourage deep breaths that prevent atelectasis and chest infection
Shallow breathing after surgery lets alveoli collapse, causing atelectasis and pneumonia. Deep-breathing exercises with an incentive spirometer help keep the lungs expanded.
答案: A · To shift potassium into cells; blood glucose must be monitored for hypoglycaemia
Insulin drives potassium into cells, temporarily lowering serum levels. Glucose is given to prevent hypoglycaemia, but glucose monitoring is still needed for several hours.
答案: B · A rise in serum uric acid
Thiazides reduce uric acid excretion and can trigger gout. They also tend to lower potassium, sodium and magnesium, raise calcium (by reducing its excretion) and raise blood glucose and lipids.核对依据: Hydrochlorothiazide · StatPearls (NCBI Bookshelf) (2026)
答案: A · "I'll take my iron tablet with a big glass of milk"
Calcium in milk, as well as antacids and tea, reduces iron absorption, so iron should not be taken with them. Vitamin C improves absorption, dark stools are expected, and iron overdose is a serious poisoning risk in young children.核对依据: Iron deficiency anemia - Medical Encyclopedia · MedlinePlus (NIH) (2025); Iron in diet - Medical Encyclopedia · MedlinePlus (NIH) (2025)
答案: B · 高血压危象
肠道中的 MAO 通常会分解饮食中的酪胺。MAO 被抑制后,来自陈年奶酪等食物的酪胺进入循环并释放去甲肾上腺素,导致血压危险地升高。
答案: D · Digoxin levels rise, so the digoxin dose is often reduced
Amiodarone inhibits P-glycoprotein and reduces digoxin clearance, so digoxin levels rise. The digoxin dose is often reduced, and the patient is monitored for bradycardia and toxicity; amiodarone also raises warfarin levels.
答案: C · 吸入性肺炎
卒中后的吞咽困难增加了误吸的风险。误吸物常进入右下叶,因为右主支气管更宽、更垂直。吞咽筛查、直立体位和口腔护理可降低风险。
答案: D · CURB-65 评分为 5:高风险,需要紧急高级医师评估
该患者得分为 5 分(满分 5 分):意识混乱、尿素 >7 mmol/L、呼吸频率 ≥30 次/分、低血压和年龄 ≥65 岁。这提示重症肺炎,死亡率高,患者同时符合可能脓毒症的标准。需要迅速上报、静脉抗生素、补液,并评估是否需要重症监护。
答案: D · This is normal, because the conduit is made from bowel
An ileal conduit uses a piece of small bowel, which keeps making mucus. Mucus in the urine is expected. Good fluid intake helps keep it moving. Fever, cloudy foul urine or a change in stoma colour should be reported.
答案: A · 停止输注并紧急呼叫卒中团队
溶栓期间或之后新出现的头痛、呕吐、高血压或神经功能恶化,可能提示症状性颅内出血。应停止输注,安排紧急医疗评估,并预期紧急 CT 扫描和凝血检查。
答案: C · Glasgow-Blatchford 评分
Glasgow-Blatchford 评分使用尿素、血红蛋白、收缩压、脉搏、黑便、晕厥、肝病和心力衰竭,来识别需要干预的患者。完整的 Rockall 评分在内镜检查后使用。
答案: A · Toxic megacolon
Toxic megacolon is dilatation of the inflamed colon with systemic toxicity and a high risk of perforation. Antimotility drugs and opioids are avoided, an abdominal X-ray is done and the surgical team is involved.
答案: D · Tone, trauma, tissue and thrombin
The 4 Ts are tone (atony), trauma (tears, haematomas, rupture), tissue (retained placenta or clots) and thrombin (clotting disorders). Tone is the most common cause.
答案: B · Leg weakness or numbness causing a fall
After an epidural, the nurse checks that leg sensation and strength have returned before she stands. Combined with orthostatic hypotension and blood loss, this makes the first walk a high fall risk.
答案: A · 旧房子中剥落的旧油漆和灰尘
旧建筑中的含铅油漆、被污染的灰尘和土壤以及一些进口产品是常见来源。铅会影响发育中的大脑,造成学习和行为问题。
答案: A · Encourage her to keep coughing and stay with her, watching closely
A child who can cough effectively and speak has a partly open airway. Back blows or thrusts are not started, and blind finger sweeps can push the object further in. If the cough becomes ineffective, back blows and abdominal thrusts are given.
答案: D · "Are you having thoughts of killing yourself?"
Asking directly and calmly shows that it is safe to talk. Questions that suggest the "right" answer, or that minimise the problem, make it harder for the patient to be honest.
答案: A · Protect him from ridicule, avoid arguing and focus on real activities
Arguing or agreeing strengthens a delusion. The nurse protects the patient's dignity, responds to his feelings and focuses on real, present activities and concerns.
答案: m = 2.36 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: D = 33.3 mcg/min
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 = 40 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 = 3.1 mL
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
答案: R = 61.43 mL/h
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.
许多医院允许在不重开医嘱的情况下进行不超过 25% 的此类调整;请查阅本院规定。
答案: Δ = 12 %
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.
许多医院允许在不重开医嘱的情况下进行不超过 25% 的此类调整;请查阅本院规定。
答案: R = 3.9 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 = 13.1 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 = −695 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。
为负:患者丢失的液体多于摄入的液体。
答案: t = 5.3 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 5 h 20 min,所以袋子大约在 18:20 输完。
答案: MFS = 100
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: 体重过轻
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: 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。
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: 每个 QRS 对应的扑动波 = 4
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: 心室率 = 50 bpm
房室传导阻滞:逐个标出 P 波,检查哪些 P 波后面跟着 QRS。一度:每个 P 波都下传,PR 恒定且大于 0.20 s。二度 I 型(Mobitz I,文氏现象):PR 逐搏延长,直到一个 P 波未下传,然后周期重新开始(成组搏动)。二度 II 型(Mobitz II):下传搏动的 PR 保持恒定,P 波突然不下传;QRS 常增宽。三度(完全性)阻滞:P 波和 QRS 波群各自规则但互相独立,PR 随机变化,心房率快于逸搏率(交界性逸搏 40–60 次/分,QRS 窄;室性逸搏 20–40 次/分,QRS 宽)。2:1 阻滞仅凭一份条带无法判断是 I 型还是 II 型。
二度 II 型:每 3 个 QRS 波群对应 4 个 P 波,PR 恒定。
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