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 with capacity wants to leave hospital against medical advice. What should the nurse do?
An older woman has been lying on the floor at home all night after a fall. Which complications should the nurse look for in particular?
During a surgical hand scrub, how are the hands held?
While preparing an IV medication, a nurse sees that the syringe tip touched the medication tray after the cap came off. What should the nurse do?
Two nursing assistants argue loudly at the station about their assignments. What is the charge nurse’s best first step?
一名 LPN/LVN 报告说一名稳定的患者现在出现新的胸痛。RN 应怎么做?
A patient has a fentanyl patch for chronic pain. Which advice is correct?
一名髋部骨折的老年患者在受伤两天后出现气短、意识混乱,胸部有瘀点状皮疹。应怀疑哪种并发症?
A patient with central diabetes insipidus starts desmopressin. Which laboratory result is most important to monitor for an adverse effect?
A patient with acute kidney injury after severe dehydration has a rising creatinine. Which urine findings support a prerenal cause rather than acute tubular necrosis (ATN)?
When should a patient take a once-daily proton pump inhibitor such as omeprazole?
哪种抗癫痫药在妊娠期服用时,引起神经管缺陷和发育问题的风险是众所周知最高的?
A nurse measures blood pressure on a large upper arm using a cuff that is too small. What effect will this have?
通常教授的胸腔引流管拔除方法是哪种?
A conscious patient with a glucose of 3.1 mmol/L (56 mg/dL) can swallow safely. Which is the best first treatment?
一名 DKA 患者正在好转:血糖 9 mmol/L,酮体 0.4 mmol/L,pH 7.36。患者能进食和饮水。应如何停用静脉胰岛素?
How does sucralfate help a peptic ulcer heal?
一名高压电损伤的患者有小的入口和出口伤口。为什么需要密切监测?
A woman at 10 weeks has morning sickness. Which suggestion is most likely to help?
新生儿腋温为 36.0 °C。最恰当的首要措施是什么?
A child with suspected measles is admitted. Which precaution is most important?
一名患幽门狭窄的 5 周龄婴儿准备手术。血液检查显示低氯和代谢性碱中毒。手术前的优先事项是什么?
A patient at high risk of suicide is placed on constant (one-to-one) observation. What does this mean?
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)。 一次体重换算得到 51.0080 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)。 一次输注从 20:55 开始,到次日早晨 05:40 结束(24 小时制)。它运行了多少分钟t?
一支肾上腺素安瓿标示为 1:1000(1 mg/mL)。医嘱为 0.3 mg 肌内注射(IM),用于严重过敏反应。你应抽取多少体积 V?
处方剂量为 1480 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?
医嘱要求在 8 小时内输入 1500 mL。3 小时后你发现袋中还剩 1010 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?
将 500 mg 药物稀释于 250 mL 中,通过滴系数为 60 gtt/mL 的输液器重力滴注。医嘱为每小时 80 mg。求滴速 R,以每分钟滴数表示。
练习题(虚构数值,不作为临床指导)。 一份含 100 单位普通胰岛素、容量 250 mL 的输液以 2 mL/h 输注。患者每小时接受多少单位 D?
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 15 mL/h 输注。患者体重 87 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 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)。 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 12:15 开始用输液泵以 100 mL/h 输注。到 15:45 时袋中还剩多少 mL V?
练习题(虚构数值,不作为临床指导)。 用 Braden 量表评估一位练习患者:感觉知觉: 完全受限; 潮湿程度: 持续潮湿; 活动: 卧床不起; 活动能力: 非常受限; 营养: 极好; 摩擦力和剪切力: 潜在问题。求 Braden 总分B。
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 12 次/分,SpO₂ 98%吸室内空气,血压 222/134 mmHg,脉搏 58 次/分,清醒,体温 36.8 °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 7.44,PaCO₂ 26 mmHg (3.5 kPa),HCO₃⁻ 17 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。
在海平面,某练习血气取自吸入 21% 氧气时,显示 PaO₂ 80 mmHg (10.7 kPa),PaCO₂ 36 mmHg (4.8 kPa)。用 PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 求A–a 梯度。
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)。
这条 II 导联心电图显示心房与心室之间存在传导问题。这是什么节律?点击你的答案。
答案: A · Explain the risks, inform the doctor and document the discussion
An adult with capacity can discharge themselves. The nurse explains the risks, involves the doctor, offers follow-up and documents the decision; detaining them would be unlawful.
答案: B · Pressure damage, hypothermia and muscle breakdown
A long lie causes pressure injury, hypothermia, dehydration and rhabdomyolysis, which can damage the kidneys. The patient is assessed carefully for these as well as for fractures.
答案: B · Above the elbows, so water runs from the fingertips toward the elbows
After a surgical scrub, the hands are the cleanest area, so they are held above the elbows to let water drain away from them toward the less clean elbows.
答案: B · Discard the syringe and prepare the dose again with new equipment
In aseptic non-touch technique, key parts such as syringe tips and IV hubs must not touch any non-sterile surface. A contaminated key part is not cleaned and reused. It is replaced.
答案: D · Meet both of them privately to hear each side
Talking with both staff members privately allows the charge nurse to understand the problem and look for a fair solution. Ignoring the conflict or acting without facts usually makes it worse.
答案: A · 亲自评估患者并决定下一步
当稳定的患者出现新问题时,RN 应评估患者,因为患者现在可能不稳定。然后 RN 决定干预措施和上报,可能包括心电图和处方的硝酸甘油。
答案: D · Avoid heat sources such as hot water bottles over the patch
Heat increases absorption of fentanyl through the skin and can cause overdose. Old patches are removed and folded before disposal, and patches should not be cut unless the product allows it.
答案: A · 脂肪栓塞综合征
脂肪栓塞通常在长骨或骨盆骨折后 24–72 小时出现,表现为呼吸窘迫、神经系统改变和瘀点状皮疹三联征。
答案: A · Serum sodium, which may fall too low
Desmopressin acts like ADH, so the kidneys retain water. If the patient drinks too much, water retention can cause hyponatremia, which may lead to confusion and seizures. Sodium, weight and fluid balance are monitored.
答案: D · Low urine sodium and concentrated urine with a high specific gravity
In prerenal AKI the tubules are intact, so they keep sodium and water, giving a low urine sodium and concentrated urine. In ATN the damaged tubules cannot do this, so urine sodium is high, the urine is dilute and muddy brown casts appear.核对依据: Urine specific gravity test · MedlinePlus (NIH) (2025)
答案: D · About 30–60 minutes before the first meal of the day
Proton pump inhibitors block pumps that are active, so they work best when taken before breakfast. Food then activates the pumps when the drug level is high.
答案: B · 丙戊酸钠
丙戊酸盐具有强致畸性,可引起神经管缺陷和其他畸形,并影响神经发育。除非没有其他有效替代药物,妊娠期应避免使用。
答案: D · The reading will be falsely high
A cuff that is too small needs a higher pressure to compress the brachial artery, giving a falsely high reading. A cuff that is too large can give a falsely low reading. The bladder should encircle most of the arm, so cuff size is chosen by arm circumference.
答案: A · 在屏气或呼气时拔除,然后封闭伤口
许多指南建议在深吸气末屏气(Valsalva)或呼气时拔管,使胸腔内为正压。伤口用缝线或密闭敷料封闭,监测患者有无气胸复发,必要时拍胸部 X 线。事先给予镇痛是良好的做法。
答案: D · Glucose tablets or a small glass of fruit juice
About 15–20 g of fast-acting carbohydrate, such as glucose tablets or juice, raises glucose quickly. Chocolate and milk contain fat, which slows absorption. Glucose is rechecked after about 15 minutes.
答案: D · 随餐给予皮下胰岛素,重叠一段时间后停止静脉输注
静脉胰岛素的半衰期很短。在皮下胰岛素起效前停用会导致反跳性酮症。应给予皮下胰岛素,并将输注继续一段设定的重叠时间(随餐给予速效胰岛素后常为 30–60 分钟)。现代方案中,输注期间常继续使用基础胰岛素。
答案: B · It forms a protective coating over the ulcer base
Sucralfate binds to the ulcer base and forms a barrier against acid and pepsin. It works best on an empty stomach and can reduce the absorption of other drugs, so doses are separated.
答案: A · 隐匿的肌肉损伤:心律失常、横纹肌溶解、肾损伤
电流沿神经、血管和肌肉传导,在小的皮肤伤口下造成深部损伤。患者需要心电监护、评估骨筋膜室综合征,以及检查尿中肌红蛋白(尿色深),如存在肌红蛋白尿,则提高尿量目标。
答案: C · Eat dry crackers before rising and eat small meals
Eating something dry before rising, small frequent meals, and drinking fluids between rather than with meals reduce nausea. Fatty and spicy foods tend to worsen it.
答案: D · 让婴儿与母亲进行皮肤接触,盖好被子并戴上帽子
体温低于约 36.5 °C 为偏低。用毯子和帽子进行皮肤接触可使婴儿升温。应复测体温和血糖,因为冷应激会消耗葡萄糖并可导致低血糖。洗澡会增加热量丢失。
答案: C · Airborne precautions, ideally in a negative-pressure room
Measles spreads through the air and can remain in a room for up to about 2 hours. Airborne precautions, a negative-pressure room where available and immune staff are required.
答案: C · 按处方静脉补液,纠正脱水和电解质失衡
反复呕吐导致脱水以及低氯性、低钾性代谢性碱中毒。应首先纠正这些问题,因为在液体和电解质恢复正常之前麻醉不安全。幽门肌切开术不是急诊手术。
答案: A · A staff member stays with the patient at all times, at the distance set by policy, including in the bathroom
Constant observation means a member of staff is always with the patient, at a distance set by policy, so they can intervene immediately. It is reviewed regularly and stepped down as risk reduces.
答案: D · 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: x = 51 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: t = 525 min
24 小时制:下午 1 点起,小时数加 12(下午 3:45 = 15:45)。午夜到凌晨 12:59 为 00:00–00:59,中午 12:00–12:59 仍为 12:00–12:59。反过来换算时,13–23 点减 12 并标为下午;00 点变为凌晨 12 点。跨午夜计算时间要分两段:先算到 24:00(00:00),再从 00:00 算起。
答案: V = 0.3 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.
美国的标签现在标示 mg/mL(1 mg/mL = 1:1000;0.1 mg/mL = 1:10 000)。切勿静脉推注 1 mg/mL 的肾上腺素。
答案: V = 0.74 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 = 202 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: R = 40 gtt/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: D = 0.8 件/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: D = 4.6 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: B = 130 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。
为正:摄入的液体多于排出的液体。
答案: V = 650 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: B = 11
Braden 量表:评估压力性损伤风险的六个分项。感觉知觉、潮湿程度、活动、活动能力和营养各评 1 至 4 分,从最差水平(1)到无问题(4);摩擦力和剪切力评 1 至 3 分。总分为 6 至 23,总分越低风险越高。常用分级:19–23 无风险,15–18 轻度风险,13–14 中度风险,10–12 高风险,9 分及以下为极高风险。
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。
答案: A–a 梯度 = 24.73 mmHg
衍生数值:计算所得的血清渗透压为 2·Na⁺ + 葡萄糖 + 尿素,各值均以 mmol/L 计(葡萄糖和 BUN 以 mg/dL 计时为 2·Na⁺ + 葡萄糖/18 + BUN/2.8);正常约为 275–295 mOsm/kg。P/F 比值是 PaO₂ 除以以小数表示的 FiO₂。海平面的肺泡氧分压为 PAO₂ = FiO₂·(760 − 47) − PaCO₂/0.8 mmHg,A–a 梯度为 PAO₂ − PaO₂。
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: 三度(完全性)房室传导阻滞
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。
II 型和三度阻滞可能突然进展,所以教科书将它们列为比 I 型更严重。
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