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

护士发现一名患者躺在床边的地板上。首要行动是什么？

  1. A在移动患者之前，评估其反应性和损伤情况
  2. B在同事的帮助下立即把患者扶回床上
  3. C趁细节清晰时填写事件报告
  4. D打电话给患者家属解释发生了什么
2.优先排序与委派困难

A patient with septic shock remains hypotensive, with a mean arterial pressure of 58 mmHg, after adequate IV fluids. What should the nurse anticipate?

  1. AAn oral fluid challenge with a sports drink
  2. BA vasopressor, such as norepinephrine, to raise the pressure
  3. CA loop diuretic to remove the extra fluid that has been given
  4. DA beta-blocker to slow the heart rate
3.感染控制与患者安全中等

Why can side rails be dangerous for a confused, restless patient?

  1. AThe patient may climb over them or get trapped in gaps
  2. BSide rails always cause pressure injuries
  3. CSide rails make the bed move by itself
  4. DSide rails stop staff from reaching the patient in an emergency
4.感染控制与患者安全困难

During flu season, a nurse wakes up with fever, cough and muscle aches. What is the best action?

  1. AGo to work but avoid caring for patients who have weak immune systems
  2. BTake an antipyretic so the fever does not show at work
  3. CGo to work but wear a surgical mask for the whole shift
  4. DStay home and inform the employer according to the illness policy
5.实验室检查值与电解质中等

A patient's potassium is unexpectedly 5.8 mEq/L. The sample was taken after the tourniquet was on for several minutes while the patient pumped their fist. What is the best interpretation?

  1. ATourniquet time affects only the glucose result, not the potassium
  2. BFist pumping lowers potassium, so the true level is even higher
  3. CThe result may be falsely high and should be repeated with better technique
  4. DThe result confirms true hyperkalemia and needs no further checking
6.实验室检查值与电解质困难

一名营养不良的患者重新开始进食，第 3 天磷酸盐为 1.2 mg/dL（0.39 mmol/L），伴肌无力和气短。主要风险是什么？

  1. A细胞释放钾引起高钾血症
  2. B体重快速增加，但没有严重危险
  3. C低磷导致呼吸肌无力和心力衰竭
  4. D骨骼释放钙引起肾结石
7.临床护理中等

即将开始输血。最重要的安全核查是什么？

  1. A只核对患者体重
  2. B在床旁确认患者身份并与血液成分核对一致
  3. C用微波炉加热所有血液
  4. D核对患者的饮食偏好
8.临床护理困难

Which sign is often a late finding in hypovolaemic shock in a young, previously fit adult?

  1. AA rise in heart rate
  2. BCool peripheries
  3. CA fall in blood pressure
  4. DA slightly raised respiratory rate
9.内外科护理：心血管与呼吸中等

Why is aspirin chewed rather than swallowed whole in a suspected acute coronary syndrome?

  1. AChewing changes aspirin into an anticoagulant
  2. BChewing stops the aspirin from irritating the lining of the stomach
  3. CWhole aspirin tablets cannot be absorbed at all from the gut
  4. DChewing speeds absorption, giving a faster antiplatelet effect
10.内外科护理：心血管与呼吸困难

一名 NSTEMI 后放置了冠状动脉支架的患者问为什么要服用两种抗血小板药。哪个回答最准确？

  1. A第二种药保护胃黏膜免受阿司匹林的伤害
  2. B阻断了两条通路，保护支架，但出血风险增加
  3. C第二种药可溶解导致最初心脏病发作的血栓
  4. D这两种药降低胆固醇，使新的堵塞不会形成
11.内外科护理：神经、内分泌与肾脏中等

Which statement about giving IV potassium is correct?

  1. AIt is safest given through a small vein in the hand at a fast rate
  2. BIt is diluted and given through an infusion pump, never as a bolus
  3. CIt needs no monitoring at all once the infusion is running
  4. DIt can be given quickly as a push to correct the level fast
12.内外科护理：神经、内分泌与肾脏困难

A patient with an external ventricular drain sat up in bed without help. The drain stayed at its old height, and the drainage bag filled quickly. The patient now has a headache. What is the concern?

  1. ANo concern, because more drainage always lowers the ICP safely
  2. BUnderdrainage, so the drain should be lowered further
  3. COverdrainage of CSF, so act per protocol and inform the team
  4. DAn infected drain, so the dressing should be removed
13.内外科护理：消化、围手术期与肿瘤中等

Which medicine commonly delays wound healing?

  1. ALong-term corticosteroids
  2. BParacetamol
  3. CVitamin C supplements
  4. DSaline eye drops
14.内外科护理：消化、围手术期与肿瘤困难

A patient on warfarin has a major upper GI bleed with an INR of 5. Which treatment should the nurse anticipate to reverse the warfarin?

  1. AProthrombin complex concentrate with IV vitamin K
  2. BMore warfarin to stabilise the INR
  3. COral aspirin to balance the clotting system quickly
  4. DProtamine sulfate on its own

3溶液

1.优先排序与委派

答案: A · 在移动患者之前，评估其反应性和损伤情况

为什么是这个答案

护士首先检查反应性、呼吸和头部外伤或髋部骨折等损伤。然后才在帮助下安全地移动患者。通知医疗人员，之后再完成报告。

答案

A · 在移动患者之前，评估其反应性和损伤情况
2.优先排序与委派

答案: B · A vasopressor, such as norepinephrine, to raise the pressure

为什么是这个答案

If hypotension continues after fluid resuscitation, a vasopressor such as norepinephrine is started to keep the MAP at least 65 mmHg. Diuretics and beta-blockers would worsen perfusion.

答案

B · A vasopressor, such as norepinephrine, to raise the pressure
3.感染控制与患者安全

答案: A · The patient may climb over them or get trapped in gaps

为什么是这个答案

Confused patients may climb over rails and fall from a greater height or become trapped between the rail and mattress. Alternatives such as low beds and close observation are often safer.

答案

A · The patient may climb over them or get trapped in gaps
4.感染控制与患者安全

答案: D · Stay home and inform the employer according to the illness policy

为什么是这个答案

Health care workers with signs of influenza should not work, because they can infect patients and colleagues. They follow the employer’s policy on when they may return.

答案

D · Stay home and inform the employer according to the illness policy
5.实验室检查值与电解质

答案: C · The result may be falsely high and should be repeated with better technique

为什么是这个答案

Repeated fist clenching and a long tourniquet time release potassium from muscle and can cause hemolysis, both of which give a falsely high potassium. The patient is assessed and the test is repeated with correct technique; true hyperkalemia must not be missed.

答案

C · The result may be falsely high and should be repeated with better technique
6.实验室检查值与电解质

答案: C · 低磷导致呼吸肌无力和心力衰竭

为什么是这个答案

重新开始喂养时，胰岛素把磷酸盐推入细胞内，因此血清磷酸盐可急剧下降（再喂养综合征）。严重低磷血症使膈肌和心脏无力。应补充磷酸盐，并缓慢增加喂养量。

答案

C · 低磷导致呼吸肌无力和心力衰竭
7.临床护理

答案: B · 在床旁确认患者身份并与血液成分核对一致

为什么是这个答案

在床旁将患者腕带上的身份信息与配血标签和医嘱进行核对。开始输血前测量基线生命体征。

答案

B · 在床旁确认患者身份并与血液成分核对一致
8.临床护理

答案: C · A fall in blood pressure

为什么是这个答案

Young adults compensate for blood loss with tachycardia and vasoconstriction, so blood pressure may stay normal until a large volume is lost. Hypotension is therefore a late and serious sign.

答案

C · A fall in blood pressure
9.内外科护理：心血管与呼吸

答案: D · Chewing speeds absorption, giving a faster antiplatelet effect

为什么是这个答案

Aspirin irreversibly inhibits platelet cyclo-oxygenase, reducing thromboxane A2 and platelet aggregation. Chewing a non-enteric-coated tablet speeds absorption. It reduces mortality in acute coronary syndromes and is given unless there is a true allergy.

答案

D · Chewing speeds absorption, giving a faster antiplatelet effect
10.内外科护理：心血管与呼吸

答案: B · 阻断了两条通路，保护支架，但出血风险增加

为什么是这个答案

双联抗血小板治疗（阿司匹林加氯吡格雷、替格瑞洛或普拉格雷等 P2Y₁₂ 抑制剂）可减少复发事件和支架血栓，通常持续最长 12 个月。它会增加出血风险，没有心脏科建议不得提前停药，尤其是在支架术后。

答案

B · 阻断了两条通路，保护支架，但出血风险增加
11.内外科护理：神经、内分泌与肾脏

答案: B · It is diluted and given through an infusion pump, never as a bolus

为什么是这个答案

Concentrated potassium given quickly can cause fatal arrhythmias. IV potassium is given in a diluted, ready-made solution through an infusion pump at a controlled rate, with monitoring of potassium and, at higher rates, the ECG.

答案

B · It is diluted and given through an infusion pump, never as a bolus
12.内外科护理：神经、内分泌与肾脏

答案: C · Overdrainage of CSF, so act per protocol and inform the team

为什么是这个答案

When the head rises above the drain level, CSF drains faster. Overdrainage can cause headache, collapse of the ventricles or a subdural bleed. The nurse follows the protocol (often clamping briefly and re-levelling) and informs the neurosurgical team.

答案

C · Overdrainage of CSF, so act per protocol and inform the team
13.内外科护理：消化、围手术期与肿瘤

答案: A · Long-term corticosteroids

为什么是这个答案

Corticosteroids suppress the inflammatory phase, collagen formation and immunity, delaying healing and raising infection risk. Other factors include diabetes, smoking, malnutrition, poor perfusion and chemotherapy.

答案

A · Long-term corticosteroids
14.内外科护理：消化、围手术期与肿瘤

答案: A · Prothrombin complex concentrate with IV vitamin K

为什么是这个答案

Major bleeding on warfarin is treated by stopping it and giving prothrombin complex concentrate for rapid reversal with IV vitamin K for a lasting effect. Protamine reverses heparin, not warfarin.

答案

A · Prothrombin complex concentrate with IV vitamin K

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