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。
In adult basic life support, how long should the rescuer take to check for normal breathing?
一名成年患者缺乏就某项治疗作出决定的能力,且没有预先决定。应如何作出决定(英格兰和威尔士)?
患者的身份腕带丢失,而有一种药物到了给药时间。护士应怎么做?
A patient weighs 180 kg and needs to be moved from bed to chair. The standard ceiling lift on the unit has a lower weight limit. What should the nurse do?
A patient’s urinary catheter has drained no urine for two hours, and the lower abdomen is swollen. What should the nurse do first?
A patient with diabetes takes propranolol. Which sign of hypoglycemia is most likely to still appear?
Which examination findings suggest a large pleural effusion on one side?
A drowsy patient in recovery is making snoring sounds and the SpO2 is falling. What is the first action?
一名因房颤服用华法林的患者 INR 为 1.4。这意味着什么?
一名静脉输注胰岛素的患者血糖为 65 mg/dL(3.6 mmol/L)。最好的措施是什么?
A patient with diabetes is sweaty and shaky. Blood glucose is 3.0 mmol/L (54 mg/dL). The patient is awake and can swallow. What should the nurse do first?
A patient taking a GLP-1 receptor agonist such as semaglutide has severe, constant upper abdominal pain spreading to the back, with vomiting. What should the nurse suspect?
During an episode of chest pain, a patient's ECG shows new horizontal ST depression. What does this most likely indicate?
经桡动脉心导管检查术后,最重要的评估是什么?
A stroke patient speaks fluently, but the words make little sense, and they do not follow simple instructions. Which type of aphasia is this?
Which statement correctly distinguishes spinal shock from neurogenic shock?
Which burn should usually be discussed with a specialist burns service even if it is small?
A patient on immunotherapy for melanoma has six watery stools a day and abdominal cramps. What should the nurse do?
A woman at 28 weeks is Rh-negative and has a positive antibody screen for anti-D. What does this mean?
A newborn is cold-stressed. Which complications should the nurse anticipate?
一名儿童在同一次就诊时需要接种几种不同的疫苗。一般原则是什么?
The parents of a 9-year-old who wets the bed most nights have been punishing him. What is the best advice?
A patient with borderline personality disorder has made superficial cuts to her arm on the ward. What is the most appropriate nursing response?
开始使用 SSRI 两周后,一名患者说:“这没有用。我要停药了。”最佳回应是什么?
练习题(虚构数值,不作为临床指导)。 一次体重换算得到 58.9780 kg。 本练习的规则是:体重取到最接近的十分之一千克。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1 tbsp,每 12 小时一次,共 7 天。混悬液每瓶 150 mL。按1 tbsp = 15 mL,必须提供多少整瓶N才能完成疗程?
50 mL 的 10%(w/v)溶液中含有多少毫克药物 m?
处方为 5300 单位的药物,药液规格为 10000 单位/mL。请用 1 mL 注射器抽取剂量:应给多少体积 V?
用滴系数为 10 滴/mL 的输液器在 4 小时内输入 1500 mL。求滴速 R(滴/分)。 取整到最接近的整数。
医嘱要求在 12 小时内输入 1500 mL。4 小时后你发现袋中还剩 1220 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)。 一项练习规程要求为体重 49 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)。 一份含dopamine 800 mg、容量 500 mL 的输液以 14 mL/h 输注。患者体重 53 kg。患者接受的剂量 D 是多少 mcg/kg/min? 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)。 一袋 1000 mL 的液体于 09:30 开始用输液泵以 75 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)。 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: 否; 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 117 kg,身高 191 cm。计算 BMI 并点击 WHO 体重分类。
某练习血气显示 PaCO₂ 78 mmHg (10.4 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 pH 7.20,PaCO₂ 21 mmHg (2.8 kPa),HCO₃⁻ 8 mmol/L,Na⁺ 136,Cl⁻ 106 mmol/L。利用阴离子间隙和 Δ 比值,点选最合适的解读。
解读这条 II 导联心律条带。这是什么节律?点击你的答案。
请解读这条 II 导联心电图条带。仅凭这一条心电图条带,你能为哪种解读辩护?点击你的答案。
答案: B · No more than 10 seconds
Rescuers look, listen and feel for normal breathing for no more than 10 seconds. If breathing is absent or not normal, they call for help and start CPR.
答案: C · 以患者的最佳利益为准,考虑其以往的意愿,并征询其身边亲近的人
为缺乏能力者作出的决定必须以其最佳利益为准,考虑其过去和现在的意愿、价值观和信仰,并征询照护者和家属的意见。应选择限制最少的方案。
答案: D · 先用两项识别信息确认身份,并重新戴上新腕带
每次给药都需要确认身份。护士用两项识别信息确认患者身份后,更换腕带。熟悉程度和房间号都不是可接受的识别信息。
答案: C · Use bariatric-rated equipment and enough trained staff
Using equipment above its rated capacity can cause collapse and injury. Bariatric lifts, chairs and beds are used, with enough trained staff and a plan agreed in advance.
答案: D · Check the tubing for kinks or obstruction
Sudden lack of drainage with a full bladder usually means a kinked or blocked catheter. The nurse checks the tubing and position first, then follows the policy for irrigation or replacement.
答案: A · Sweating
Beta-blockers can hide tachycardia, palpitations and tremor during hypoglycemia. Sweating is mainly cholinergic, so it usually remains, and patients are taught to check glucose when they sweat.
答案: C · Dull percussion and reduced breath sounds over the lung base
Fluid in the pleural space muffles breath sounds and makes percussion stony dull. A large effusion may push the trachea away from the affected side.
答案: B · Open the airway with a head tilt–chin lift or jaw thrust
In a drowsy patient the tongue can fall back and obstruct the airway, causing snoring. Simple airway manoeuvres, oxygen and, if needed, an airway adjunct are used while help is called.
答案: D · 抗凝不足,更容易发生血栓和卒中
INR 低于目标范围意味着对于这一适应证来说血液凝固过于容易。应通知开医嘱者,并复核剂量和可能的原因,如漏服或药物相互作用。核对依据: Prothrombin Time Test and INR (PT/INR) · MedlinePlus (NIH) (2024)
答案: D · 遵循低血糖方案并通知医疗人员
使用胰岛素输注时血糖低于 70 mg/dL 即为低血糖。护士应遵循医院的方案,通常是停用或减少胰岛素并给予葡萄糖,频繁复查并通知医疗人员。核对依据: Low blood sugar · MedlinePlus (NIH) (2026)
答案: B · Give 15–20 g of fast-acting carbohydrate, such as juice
Conscious hypoglycaemia is treated with 15–20 g of fast-acting carbohydrate, with glucose rechecked after about 15 minutes. Fat slows absorption, and glucagon is kept for patients who cannot swallow.
答案: A · Acute pancreatitis; the drug is stopped and urgent assessment arranged
Mild nausea is common with GLP-1 agonists, but severe persistent abdominal pain radiating to the back suggests pancreatitis. The drug is stopped and the patient needs urgent assessment, including serum lipase or amylase.
答案: A · Myocardial ischaemia
New horizontal or downsloping ST depression during pain suggests myocardial ischaemia, as in unstable angina or NSTEMI. It should be reported immediately with serial ECGs and troponins. ST depression can also reflect reciprocal change opposite a STEMI.
答案: C · 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: C · Receptive (Wernicke's) aphasia
Receptive aphasia comes from damage to Wernicke's area in the dominant temporal lobe. Speech is fluent but often meaningless, and comprehension is impaired. Patients are often unaware of their errors.
答案: A · Spinal shock is lost reflexes; neurogenic shock is low BP and slow pulse
Spinal shock is the temporary loss of reflexes and tone below the injury. Neurogenic shock is hypotension and bradycardia caused by loss of sympathetic tone, usually with injuries at T6 or above. The two can occur together.
答案: C · A partial-thickness burn on the hand
Burns of the face, hands, feet, genitalia, perineum and major joints, as well as circumferential, chemical, electrical and inhalation injuries, usually need specialist advice because of their risks and functional impact.
答案: C · Escalate urgently, as immune-related colitis is likely
Severe diarrhoea on checkpoint inhibitors suggests immune-mediated colitis, which can perforate. It needs urgent assessment, infection testing and often high-dose steroids, not only antidiarrhoeals.
答案: C · She is sensitised; the fetus is watched for anaemia
If antibodies are already present, anti-D prophylaxis is of no use. Antibody levels are followed and the fetus is monitored for anaemia, often with Doppler of the middle cerebral artery.
答案: D · Hypoglycaemia, hypoxia and metabolic acidosis
Cold stress raises metabolic rate, using up glucose and oxygen. This can cause hypoglycaemia, hypoxia, anaerobic metabolism with metabolic acidosis and increased pulmonary vascular resistance.
答案: B · 可以在同一次就诊时接种,选择不同的注射部位
一次就诊接种几种疫苗是安全有效的,并可避免延误。应使用不同的注射器和部位,如在同一肢体,至少相距约 2.5 cm。除非产品是专门设计的,否则切勿混合疫苗。
答案: A · Stop punishing him, praise dry nights and consider a bedwetting alarm
Nocturnal enuresis is common and not deliberate; punishment worsens it. Support, reward systems for agreed behaviours, enuresis alarms and sometimes desmopressin are effective, along with normal daytime drinking and regular toileting.
答案: A · Treat the wounds in a calm, matter-of-fact way and assess her current risk and feelings
Wounds need care, and self-harm requires risk assessment. A calm, non-judgemental response avoids both punishment and unintended reinforcement, and helps the patient explore triggers and safer coping.
答案: C · 解释说通常需要几周才能完全起效,鼓励他继续服药,并监测他的情绪和安全
抗抑郁药需要数周才能充分发挥作用。突然停药可引起停药症状。护士应鼓励依从,监测自杀想法,并将其顾虑转告开医嘱者。
答案: x = 59 kg
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: N = 2
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: m = 5000 mg
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 = 0.53 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。
在这支 1 mL 的注射器上,每条小刻度线代表 0.01 mL。
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: Δ = 22 %
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: V = 0.69 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: D = 7 mcg/kg/min
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: I = 1600 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: V = 625 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: MFS = 80
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 I 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: HCO₃⁻ = 37.3 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: 合并正常间隙酸中毒
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: 窦性心律伴室性早搏
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: 2:1 房室传导阻滞(类型未定)
2:1 房室传导阻滞:每个 QRS 对应两个 P 波时,没有两个下传的 P 波连续出现,所以无法看出在未下传的 P 波之前,PR 间期是逐渐延长(I 型)还是保持恒定(II 型)。仅凭一条心电图条带,只能称为 2:1 房室传导阻滞;更长的条带或传导比例的改变才能决定类型。QRS 较窄时更可能是 I 型,QRS 增宽时更可能是 II 型,但两者都不能证明。
QRS 较窄时更可能是 I 型,QRS 增宽时更可能是 II 型,但只有更长的条带或传导比例的改变才能决定。
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