NCLEX 风格的优先排序与委派：速成包

公式表、每个专题的关键方法步骤和 14 道练习题，完整解答附在最后。

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1公式与方法

优先排序与委派

方法

  1. 问自己：如果什么都不做，什么会最快伤害患者。
  2. 应用 ABC（心脏骤停时为 C-A-B），然后是 Maslow 需求层次：生理需要先于安全，安全先于心理需要。
  3. 比较各选项：急性先于慢性，不稳定先于稳定，意外先于预期，全身性先于局部，并将每项发现与患者的基线对照。
  4. 除非是紧急情况，否则先评估再行动；然后选择其他步骤所依赖的那一步。
  5. 委派时核对五项正确：任务、情境、人员、指示和监督。评估、宣教和评价仍由注册护士负责。

感染控制与患者安全

方法

  1. 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。
  2. 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）。
  3. 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。
  4. 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。
  5. 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。

实验室检查值与电解质

方法

  1. 把数值与本实验室自己的参考范围比较，再与患者的基线和趋势比较。
  2. 检查标本：溶血、延迟，或在静脉输液附近采血都可能得出错误结果。
  3. 把数值与其典型体征以及引起它的药物和疾病联系起来。
  4. 注意相互作用：低钾或低镁会增加地高辛中毒的风险；脱水会使锂浓度升高。
  5. 对患者采取行动：评估，血药浓度不安全时暂停用药，复述危急值并通知开医嘱的医生。

内外科护理：心血管与呼吸

方法

  1. 说出问题所在：泵衰竭、动脉阻塞、节律、血栓、气道狭窄、感染或设备问题。
  2. 先检查危险征象：低氧、低血压、胸痛、新出现的意识模糊、冰冷无脉搏的肢体。
  3. 让氧疗与患者相匹配：大多数人为 94–98%，有 CO₂ 潴留风险者为 88–92%。
  4. 把每种药物与其检测和风险联系起来：华法林与 INR，肝素与 aPTT 和血小板，利尿剂与血钾。
  5. 选择安全的第一步措施，然后升级处理并重新评估。

内外科护理：神经、内分泌与肾脏

方法

  1. 对每位新出现意识模糊、乏力或癫痫发作的患者都检查血糖。
  2. 把意识水平作为脑部问题最早的警示；瞳孔变化和库欣三联征出现得较晚。
  3. 对于糖尿病急症，要区分 DKA（酮体、酸中毒）和 HHS（渗透压很高、脱水）；先补液。
  4. 对于钠和水，要判断是 ADH 过多（SIADH）还是缺乏（尿崩症），并缓慢纠正慢性变化。
  5. 对于肾脏问题，把原因分为肾前性、肾性或肾后性，并监测血钾和液体。

内外科护理：消化、围手术期与肿瘤

方法

  1. 想一想可能隐藏着什么：内出血、无发热的感染、SpO₂ 正常背后的通气不足。
  2. 利用术后的时间来缩小并发症的范围：出血在数小时内，胸部问题在数天内，伤口和吻合口漏出现得更晚。
  3. 对于疼痛，要评估、用多模式镇痛治疗、重新评估，并且在每次使用阿片类药物时监测镇静程度。
  4. 对于癌症患者，把低谷期的任何疾病都当作中性粒细胞减少性脓毒症处理，并了解肿瘤急症。
  5. 对于烧伤，只计算浅二度/深二度和三度的面积，从烧伤的时刻开始计算 Parkland 时间，并根据尿量调整。

2练习题

1.优先排序与委派中等

Which infant with gastroenteritis should the nurse see first?

  1. ATwo loose stools today, feeding well
  2. BLethargic, sunken fontanel, no wet diaper for 8 hours
  3. CMild diaper rash, otherwise playful
  4. DAlert, crying with tears, had a wet diaper an hour ago
2.优先排序与委派困难

A patient receiving comfort-focused end-of-life care is distressed by breathlessness. Which approach is most appropriate?

  1. AStart a series of aggressive tests to find the exact cause of the breathlessness
  2. BGive prescribed opioids and use positioning and a fan to relieve breathlessness
  3. CLeave the patient alone so they can rest
  4. DWithhold all opioids because they may slow breathing
3.感染控制与患者安全中等

Why is “QD” (once daily) on The Joint Commission’s “Do Not Use” list?

  1. AIt can be misread as QID or QOD, so the drug is given too often or too rarely
  2. BIt is only allowed for intravenous medicines
  3. CIt means “every day at bedtime” in some hospitals
  4. DIt is a Latin abbreviation, and only plain English abbreviations may be used
4.感染控制与患者安全困难

A handwritten order is hard to read, and the nurse is not sure of the drug name. What should the nurse do?

  1. AChoose the drug that seems most likely from the diagnosis
  2. BHold the drug until the next day without telling anyone
  3. CAsk a colleague to guess what it says
  4. DContact the prescriber to clarify before giving anything
5.实验室检查值与电解质中等

A urine culture report states "mixed growth of three organisms, likely contamination." What is the nurse's best response?

  1. ADiscard the report, because a mixed growth is always normal
  2. BStart treatment for all three organisms with three antibiotics
  3. CRecord the result as a confirmed urinary tract infection
  4. DInform the provider and arrange a new, correctly collected sample
6.实验室检查值与电解质困难

A patient on long-term amiodarone has fatigue and weight gain. TSH is 11 mIU/L and the free T4 is low. What is the most likely explanation?

  1. AA normal response to amiodarone needing no action
  2. BAmiodarone-induced hypothyroidism
  3. CAmiodarone-induced hyperthyroidism
  4. DSecondary hypothyroidism from pituitary failure
7.临床护理中等

A patient is having a 12-lead ECG. Where are the chest electrodes placed?

  1. AAnywhere on the chest where the skin is clear
  2. BIn standard numbered positions across the front and left of the chest
  3. COn both shoulders and both hips only
  4. DIn a straight line down the centre of the sternum from top to bottom
8.临床护理困难

A nurse teaches a patient with asthma about a new inhaled steroid "preventer". Which statement shows a need for further teaching?

  1. A"I'll keep my reliever inhaler with me."
  2. B"I will rinse my mouth after using it."
  3. C"I will only use it when I'm wheezy."
  4. D"I will use it every day even when I feel well."
9.内外科护理：心血管与呼吸中等

Which investigation is usually used to confirm a deep vein thrombosis in the leg?

  1. AA plain chest X-ray and an ECG
  2. BA lung function test
  3. CCompression duplex ultrasound
  4. DAn exercise ECG
10.内外科护理：心血管与呼吸困难

A patient with infective endocarditis is on IV gentamicin with another antibiotic. Which monitoring is most important?

  1. ADrug levels, renal function and hearing or balance changes
  2. BPeak flow readings and spirometry before and after each dose
  3. CLiver size by daily palpation and weekly abdominal ultrasound
  4. DBlood glucose only
11.内外科护理：神经、内分泌与肾脏中等

A patient has Cushing's syndrome. Which nursing assessment is especially important?

  1. AWatching for weight loss
  2. BMonitoring for a high potassium
  3. CRegular blood glucose checks
  4. DChecking for low blood pressure
12.内外科护理：神经、内分泌与肾脏困难

手术后，一名患者尿量连续 3 小时为 15 mL/h，脉搏 110 次/分，血压 96/58 mmHg，黏膜干燥。尿量少最可能的原因是什么？

  1. A静脉输液引起的液体过多
  2. B低血容量引起的肾前性 AKI
  3. C手术引起的 SIADH
  4. D麻醉后的尿崩症
13.内外科护理：消化、围手术期与肿瘤中等

Why is pethidine (meperidine) generally avoided for regular pain relief?

  1. AIt has no pain-relieving effect at all in adults
  2. BIt always causes severe diarrhoea
  3. CIt can only be given by mouth
  4. DA metabolite can build up and cause seizures
14.内外科护理：消化、围手术期与肿瘤困难

A nurse teaches a patient to self-inject low molecular weight heparin at home. Which statement shows a need for further teaching?

  1. A"I'll change the injection site each day."
  2. B"I'll put the used syringe in the sharps bin."
  3. C"I'll rub the area afterwards to spread the medicine."
  4. D"I'll report any unusual bruising or bleeding."

3溶液

1.优先排序与委派

答案: B · Lethargic, sunken fontanel, no wet diaper for 8 hours

为什么是这个答案

Lethargy, a sunken fontanel and no urine for hours suggest severe dehydration, which can lead to shock in infants. The other infants are well hydrated.

答案

B · Lethargic, sunken fontanel, no wet diaper for 8 hours
2.优先排序与委派

答案: B · Give prescribed opioids and use positioning and a fan to relieve breathlessness

为什么是这个答案

In palliative care, opioids are used to relieve breathlessness, along with positioning, a fan and calm reassurance. The aim is comfort, not more investigations.

答案

B · Give prescribed opioids and use positioning and a fan to relieve breathlessness
3.感染控制与患者安全

答案: A · It can be misread as QID or QOD, so the drug is given too often or too rarely

为什么是这个答案

“QD” and “QOD” can be confused with each other and with “QID”, leading to serious dosing errors. The word “daily” or “every other day” is written in full instead.

答案

A · It can be misread as QID or QOD, so the drug is given too often or too rarely
4.感染控制与患者安全

答案: D · Contact the prescriber to clarify before giving anything

为什么是这个答案

Illegible or unclear orders are clarified directly with the prescriber. The nurse never guesses, and a held dose is reported so treatment is not missed.

答案

D · Contact the prescriber to clarify before giving anything
5.实验室检查值与电解质

答案: D · Inform the provider and arrange a new, correctly collected sample

为什么是这个答案

Several organisms in one urine sample usually mean contamination from the skin or perineum during collection. The provider is informed, and a new clean-catch or catheter-port sample is usually needed before an infection can be confirmed.

答案

D · Inform the provider and arrange a new, correctly collected sample
6.实验室检查值与电解质

答案: B · Amiodarone-induced hypothyroidism

为什么是这个答案

Amiodarone is rich in iodine and can cause either hypothyroidism or hyperthyroidism. A high TSH with a low free T4 shows primary hypothyroidism, so thyroid function is monitored before and during therapy; liver tests are monitored too.核对依据: Hypothyroidism · MedlinePlus (NIH) (2024)

答案

B · Amiodarone-induced hypothyroidism
7.临床护理

答案: B · In standard numbered positions across the front and left of the chest

为什么是这个答案

The six chest leads (V1–V6) have standard anatomical positions, from the 4th intercostal space beside the sternum to the mid-axillary line. Wrong placement can change the ECG and lead to misinterpretation.

答案

B · In standard numbered positions across the front and left of the chest
8.临床护理

答案: C · "I will only use it when I'm wheezy."

为什么是这个答案

Inhaled corticosteroids must be used regularly to reduce airway inflammation and prevent attacks. The short-acting reliever is used for symptoms.

答案

C · "I will only use it when I'm wheezy."
9.内外科护理：心血管与呼吸

答案: C · Compression duplex ultrasound

为什么是这个答案

Compression ultrasound shows whether a deep vein is compressible and whether flow is normal; a vein containing clot does not compress. A low clinical probability with a negative D-dimer can rule out DVT without imaging.

答案

C · Compression duplex ultrasound
10.内外科护理：心血管与呼吸

答案: A · Drug levels, renal function and hearing or balance changes

为什么是这个答案

Gentamicin is nephrotoxic and ototoxic. Levels are measured to guide dosing, renal function is checked regularly and patients are asked about tinnitus, hearing loss and dizziness. Risk is greater with loop diuretics, older age and longer courses.

答案

A · Drug levels, renal function and hearing or balance changes
11.内外科护理：神经、内分泌与肾脏

答案: C · Regular blood glucose checks

为什么是这个答案

Cortisol raises blood glucose, so hyperglycaemia and diabetes are common. Hypertension, hypokalaemia, infection and fragile skin are other problems to watch for.

答案

C · Regular blood glucose checks
12.内外科护理：神经、内分泌与肾脏

答案: B · 低血容量引起的肾前性 AKI

为什么是这个答案

心动过速、低血压和黏膜干燥提示低血容量，使肾灌注减少。护士应检查导尿管是否通畅并上报；团队通常会开具补液试验并寻找出血或大量丢失等原因。

答案

B · 低血容量引起的肾前性 AKI
13.内外科护理：消化、围手术期与肿瘤

答案: D · A metabolite can build up and cause seizures

为什么是这个答案

Pethidine's metabolite norpethidine accumulates with repeated doses or kidney impairment and can cause agitation, tremor and seizures. Other opioids are preferred.

答案

D · A metabolite can build up and cause seizures
14.内外科护理：消化、围手术期与肿瘤

答案: C · "I'll rub the area afterwards to spread the medicine."

为什么是这个答案

Rubbing the site after LMWH increases bruising and is avoided. Rotating sites, reporting bleeding and safe sharps disposal are correct.

答案

C · "I'll rub the area afterwards to spread the medicine."

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