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

A nurse teaches a patient who uses home oxygen. Which statement shows a need for further teaching?

  1. A“I will not use oil-based creams on my face.”
  2. B“I will keep the oxygen away from the gas stove.”
  3. C“I will put up no-smoking signs at the front door and in my room.”
  4. D“My husband can smoke in my room if the window is open.”
2.优先排序与委派困难

A provider asks a nurse to perform a procedure that is outside the nurse’s scope of practice. What should the nurse do?

  1. ADo it just this once and promise the provider not to do it again
  2. BDo it, because the provider gave the instruction
  3. CAsk a nursing assistant to do it instead
  4. DDecline, explain why and suggest who can safely do it
3.感染控制与患者安全中等

Which drugs are used as antidotes for nerve agent poisoning?

  1. ANaloxone and flumazenil
  2. BVitamin K and protamine
  3. CAtropine and pralidoxime
  4. DAcetylcysteine and charcoal
4.感染控制与患者安全困难

A patient with fever and a spreading rash is suspected of having smallpox. Which precautions are needed?

  1. ADroplet precautions with a surgical mask
  2. BContact precautions only
  3. CAirborne and contact precautions
  4. DStandard precautions only
5.实验室检查值与电解质中等

A trauma patient receives 2 L of IV crystalloid. The hemoglobin falls from 13.0 to 11.4 g/dL (130 to 114 g/L), and the vital signs are now stable. Which explanation is most likely?

  1. AA laboratory error in the first sample
  2. BA sudden failure of the bone marrow
  3. CIncreased red cell production
  4. DDilution of the blood by the IV fluid
6.实验室检查值与电解质困难

Ten days after chemotherapy, a patient has a platelet count of 9 × 10³/µL and reports a sudden severe headache and blurred vision. What is the priority?

  1. AEncourage the patient to drink more fluids and check the blood pressure later
  2. BAssess neurological status and report it at once as possible brain bleeding
  3. CGive acetaminophen (paracetamol) for the headache and reassess in 1 hour
  4. DDim the lights and encourage rest, as headaches are common after chemotherapy
7.临床护理中等

In suspected sepsis, what should ideally be collected before the first dose of antibiotics, as long as it does not delay treatment?

  1. AA stool sample for occult blood
  2. BBlood cultures
  3. CA fasting cholesterol level
  4. DA 24-hour urine collection
8.临床护理困难

A patient is admitted with suspected meningococcal disease. Which infection control measure is usually needed?

  1. AAirborne precautions with a negative-pressure room for the whole hospital stay
  2. BIsolation only after the patient has gone home
  3. CDroplet precautions until 24 hours of effective antibiotics have been given
  4. DNo precautions, because it is not contagious
9.内外科护理：心血管与呼吸中等

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？

  1. A吸入性肺炎
  2. B左心衰竭
  3. C肺栓塞
  4. D急性哮喘
10.内外科护理：心血管与呼吸困难

After four days of antibiotics for pneumonia, a patient still has fever and pleuritic pain. There is dullness and reduced breath sounds at the right base. What complication should be suspected?

  1. AA parapneumonic effusion or empyema
  2. BAn allergic reaction to the antibiotic
  3. CNormal recovery from pneumonia
  4. DAsthma triggered by the infection
11.内外科护理：神经、内分泌与肾脏中等

A patient with Graves' eye disease has gritty eyes and swelling around them in the morning. Which advice is most appropriate?

  1. ARub the eyes firmly each morning to reduce the swelling
  2. BUse lubricating drops and sleep with the head raised
  3. CStay in bright sunlight to dry the eyes
  4. DSmoking more will not affect the eyes
12.内外科护理：神经、内分泌与肾脏困难

A drowsy patient's glucose meter shows "HI". What should the nurse do?

  1. AAssume the meter is broken and recheck tomorrow
  2. BGive glucose gel in case the reading is wrong
  3. CRecord "normal" in the notes because no number appears
  4. DTreat it as very high, check ketones and escalate
13.内外科护理：消化、围手术期与肿瘤中等

Why is IV albumin often given after a large-volume paracentesis?

  1. ATo treat infection in the ascitic fluid
  2. BTo prevent low blood pressure and kidney injury from fluid shifts
  3. CTo raise the blood glucose after the procedure
  4. DTo replace the clotting factors and platelets lost in the drained fluid
14.内外科护理：消化、围手术期与肿瘤困难

A nurse teaches a carer about overnight tube feeding at home. Which statement shows a need for further teaching?

  1. A"I'll stop the feed and call if he coughs or struggles to breathe."
  2. B"I'll check the external length mark on the tube every day."
  3. C"I'll let him lie flat so he sleeps better while the feed runs."
  4. D"I'll flush the tube with water before and after his medicines."

3溶液

1.优先排序与委派

答案: D · “My husband can smoke in my room if the window is open.”

为什么是这个答案

Oxygen supports combustion, so no one may smoke near it, even with a window open. Keeping it away from flames and avoiding oil-based products are correct.

答案

D · “My husband can smoke in my room if the window is open.”
2.优先排序与委派

答案: D · Decline, explain why and suggest who can safely do it

为什么是这个答案

Nurses must work within their legal scope of practice, even when asked by a provider. The nurse declines, explains the reason and helps find a suitable professional.

答案

D · Decline, explain why and suggest who can safely do it
3.感染控制与患者安全

答案: C · Atropine and pralidoxime

为什么是这个答案

Nerve agents inhibit acetylcholinesterase, causing excess acetylcholine. Atropine blocks muscarinic effects such as secretions and bradycardia, and pralidoxime helps to reactivate the enzyme.

答案

C · Atropine and pralidoxime
4.感染控制与患者安全

答案: C · Airborne and contact precautions

为什么是这个答案

Smallpox spreads by respiratory particles and by contact with lesions or contaminated items, so airborne and contact precautions are used. Only immunized staff should provide care where possible.

答案

C · Airborne and contact precautions
5.实验室检查值与电解质

答案: D · Dilution of the blood by the IV fluid

为什么是这个答案

IV fluids dilute the blood, so the hemoglobin falls even without further bleeding. Ongoing bleeding must still be considered, so vital signs, wounds and repeat hemoglobin values are monitored.

答案

D · Dilution of the blood by the IV fluid
6.实验室检查值与电解质

答案: B · Assess neurological status and report it at once as possible brain bleeding

为什么是这个答案

Platelet counts usually reach their lowest point (nadir) about 7–14 days after chemotherapy. With a count below 10 × 10³/µL, a sudden severe headache or visual change may signal intracranial bleeding, which is an emergency. The nurse assesses neurological status and reports it immediately.

答案

B · Assess neurological status and report it at once as possible brain bleeding
7.临床护理

答案: B · Blood cultures

为什么是这个答案

Blood cultures taken before antibiotics are more likely to grow the organism, which allows targeted treatment later. Antibiotics should still be given promptly and must not be delayed.

答案

B · Blood cultures
8.临床护理

答案: C · Droplet precautions until 24 hours of effective antibiotics have been given

为什么是这个答案

Neisseria meningitidis spreads through droplets and close contact. Droplet precautions are used until 24 hours of effective antibiotics, and public health arranges prophylaxis for close contacts.

答案

C · Droplet precautions until 24 hours of effective antibiotics have been given
9.内外科护理：心血管与呼吸

答案: A · 吸入性肺炎

为什么是这个答案

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

A · 吸入性肺炎
10.内外科护理：心血管与呼吸

答案: A · A parapneumonic effusion or empyema

为什么是这个答案

Persistent fever and signs of pleural fluid suggest a parapneumonic effusion, which may become infected (empyema). Ultrasound and diagnostic pleural aspiration are needed, and an infected collection usually needs a chest drain in addition to antibiotics.

答案

A · A parapneumonic effusion or empyema
11.内外科护理：神经、内分泌与肾脏

答案: B · Use lubricating drops and sleep with the head raised

为什么是这个答案

Lubricating drops protect the cornea, raising the head at night reduces swelling, and sunglasses help with light sensitivity. Smoking strongly worsens thyroid eye disease, so stopping is advised.

答案

B · Use lubricating drops and sleep with the head raised
12.内外科护理：神经、内分泌与肾脏

答案: D · Treat it as very high, check ketones and escalate

为什么是这个答案

"HI" means the glucose is above the meter's upper range. In a drowsy patient this may be DKA or HHS. A laboratory glucose, ketones, observations and urgent medical review are needed.

答案

D · Treat it as very high, check ketones and escalate
13.内外科护理：消化、围手术期与肿瘤

答案: B · To prevent low blood pressure and kidney injury from fluid shifts

为什么是这个答案

Removing large volumes of ascites can lead to hypotension and kidney injury as fluid moves from the blood into the abdomen. Albumin keeps fluid in the circulation; BP and urine output are monitored.

答案

B · To prevent low blood pressure and kidney injury from fluid shifts
14.内外科护理：消化、围手术期与肿瘤

答案: C · "I'll let him lie flat so he sleeps better while the feed runs."

为什么是这个答案

The head should stay raised by at least 30–45° during feeding and for a while afterwards. Flushing, checking the tube length and stopping for breathing problems are all correct.

答案

C · "I'll let him lie flat so he sleeps better while the feed runs."

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