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

On a postpartum unit, which patient is the most appropriate to assign to an LPN/LVN?

  1. AOne hour after birth with heavy bleeding and a boggy uterus
  2. BA new admission transferred from the labor ward with a fever of 38.6 °C
  3. CDay 1 after an uncomplicated vaginal birth, stable vital signs
  4. DSevere pre-eclampsia on a magnesium sulfate infusion
2.优先排序与委派困难

A child with sickle cell disease in a pain crisis develops chest pain, fever and an SpO₂ of 89%. What does this most likely mean?

  1. AA minor chest infection that can safely wait until the morning round
  2. BAn ordinary pain crisis that will improve with rest
  3. CAnxiety that will settle with reassurance
  4. DAcute chest syndrome, which needs urgent escalation and oxygen
3.感染控制与患者安全中等

哪位护士不应被分配护理带有密封放射性植入物的患者？

  1. A在本病区工作了两年的护士
  2. B接受过辐射安全培训的护士
  3. C怀孕的护士
  4. D佩戴剂量计徽章的护士
4.感染控制与患者安全困难

A nurse teaches parents about using an infant car seat. Which statement shows a need for further teaching?

  1. A“We will put the rear-facing seat in the front so we can see the baby.”
  2. B“We will make sure the harness straps are snug against the baby’s chest.”
  3. C“We will use the car seat for every trip, even short ones.”
  4. D“We will install the seat in the back seat, facing the rear.”
5.实验室检查值与电解质中等

一名患者的血小板计数为 18 × 10³/µL。哪项护理措施是恰当的？

  1. A患者头痛时给予处方的阿司匹林
  2. B使用软毛牙刷、电动剃须刀，不做肌内注射
  3. C为准确起见，每四小时经直肠测体温
  4. D鼓励每天使用牙线两次，并用锋利的剃刀刮胡子
6.实验室检查值与电解质困难

一名服用地高辛的患者血药水平为 1.2 ng/mL，钾 2.8 mEq/L，新出现频发室性早搏。最好的解释是什么？

  1. A地高辛不可能是原因，因为水平在通常范围内
  2. B钾对心律没有影响
  3. C患者需要更高剂量的地高辛来控制心律
  4. D可能存在中毒，因为低钾会增强地高辛的作用
7.临床护理中等

What should the nurse regularly check for a patient with a syringe driver?

  1. ANothing, once the syringe driver is running
  2. BOnly that the battery is charged and the device is switched on
  3. CThe infusion site, the rate and volume remaining, and the patient's symptoms
  4. DOnly the patient's weight, measured once a week on the same scales
8.临床护理困难

Three days after bowel surgery, a patient has a distended abdomen, vomiting and absent bowel sounds, without colicky pain. What is most likely?

  1. ANormal recovery after surgery
  2. BParalytic ileus
  3. CA urinary tract infection
  4. DAcute cholecystitis
9.内外科护理：心血管与呼吸中等

A patient on ramipril is to start sacubitril/valsartan for heart failure. What is the key safety point?

  1. ASacubitril/valsartan is safe to start on the same morning
  2. BBoth drugs should be taken together each day for the best effect
  3. CThe ACE inhibitor dose should be doubled during the change
  4. DThe ACE inhibitor must be stopped first, with a gap before starting
10.内外科护理：心血管与呼吸困难

A nurse teaches a patient who is starting warfarin. Which statement shows a need for further teaching?

  1. A"If I miss a dose, I will take two the next day."
  2. B"I will check before taking any new medicines or herbal remedies."
  3. C"I will have regular INR blood tests."
  4. D"I will tell my dentist that I take warfarin."
11.内外科护理：神经、内分泌与肾脏中等

A patient on insulin asks about drinking alcohol. Which advice is correct?

  1. AAlcohol raises glucose, so extra insulin should be taken first
  2. BAlcohol has no effect on blood glucose in people with diabetes
  3. CAlcohol should replace a meal on the days it is drunk
  4. DAlcohol can cause hypos, even the next day, so eat carbs with it
12.内外科护理：神经、内分泌与肾脏困难

A patient's potassium is 7.1 mmol/L, and the ECG shows peaked T waves and broad QRS complexes. What is the first treatment?

  1. AIV furosemide
  2. BOral sodium bicarbonate
  3. CIV calcium gluconate
  4. DOral potassium binder
13.内外科护理：消化、围手术期与肿瘤中等

哪种电解质异常可促成术后肠梗阻？

  1. A高钾血症
  2. B高钠血症
  3. C低钾血症
  4. D高磷血症
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 flush the tube with water before and after his medicines."
  3. C"I'll let him lie flat so he sleeps better while the feed runs."
  4. D"I'll check the external length mark on the tube every day."

3溶液

1.优先排序与委派

答案: C · Day 1 after an uncomplicated vaginal birth, stable vital signs

为什么是这个答案

A stable patient after an uncomplicated birth fits the LPN/LVN role. Heavy bleeding, magnesium infusions and new admissions with fever need RN assessment.

答案

C · Day 1 after an uncomplicated vaginal birth, stable vital signs
2.优先排序与委派

答案: D · Acute chest syndrome, which needs urgent escalation and oxygen

为什么是这个答案

Chest pain, fever and low oxygen in sickle cell disease suggest acute chest syndrome. It can worsen quickly, so oxygen, urgent review and prescribed treatment are needed.

答案

D · Acute chest syndrome, which needs urgent escalation and oxygen
3.感染控制与患者安全

答案: C · 怀孕的护士

为什么是这个答案

怀孕的工作人员和访客不应被安排接触带放射性植入物的患者。其他工作人员应限制与患者相处的时间、保持距离、使用屏蔽并佩戴剂量计。

答案

C · 怀孕的护士
4.感染控制与患者安全

答案: A · “We will put the rear-facing seat in the front so we can see the baby.”

为什么是这个答案

A rear-facing car seat must never be placed in front of an active airbag, which can strike the seat with great force. Infants ride rear-facing in the back seat, with a snug harness, on every trip.

答案

A · “We will put the rear-facing seat in the front so we can see the baby.”
5.实验室检查值与电解质

答案: B · 使用软毛牙刷、电动剃须刀，不做肌内注射

为什么是这个答案

严重血小板减少会因轻微外伤而出血。出血预防措施包括使用软毛牙刷、电动剃须刀，不做肌内注射或直肠操作，并避免使用阿司匹林和非甾体抗炎药。核对依据: Bleeding and Bruising (Thrombocytopenia) and Cancer Treatment · National Cancer Institute (NIH) (2022); Platelet Tests · MedlinePlus (NIH) (2024)

答案

B · 使用软毛牙刷、电动剃须刀，不做肌内注射
6.实验室检查值与电解质

答案: D · 可能存在中毒，因为低钾会增强地高辛的作用

为什么是这个答案

低钾增加地高辛与心肌细胞的结合，因此在正常水平也可发生中毒。护士应暂停该剂量，报告结果并预期补钾。核对依据: Low blood potassium · MedlinePlus (NIH) (2025)

答案

D · 可能存在中毒，因为低钾会增强地高辛的作用
7.临床护理

答案: C · The infusion site, the rate and volume remaining, and the patient's symptoms

为什么是这个答案

Nurses check that the infusion is running as planned, the site has no redness or swelling, and the symptoms are controlled. Problems are acted on quickly to avoid distress.

答案

C · The infusion site, the rate and volume remaining, and the patient's symptoms
8.临床护理

答案: B · Paralytic ileus

为什么是这个答案

Paralytic ileus is a temporary loss of gut movement, common after abdominal surgery. Bowel sounds are absent, unlike mechanical obstruction where they are often high-pitched. Management includes nil by mouth, NG decompression, fluids and correcting electrolytes.

答案

B · Paralytic ileus
9.内外科护理：心血管与呼吸

答案: D · The ACE inhibitor must be stopped first, with a gap before starting

为什么是这个答案

Combining an ACE inhibitor with sacubitril/valsartan greatly increases the risk of angioedema. The ACE inhibitor is stopped and a washout period (usually 36 hours) is observed before starting. Blood pressure, potassium and renal function are monitored.

答案

D · The ACE inhibitor must be stopped first, with a gap before starting
10.内外科护理：心血管与呼吸

答案: A · "If I miss a dose, I will take two the next day."

为什么是这个答案

Doubling up after a missed dose can cause over-anticoagulation and bleeding. Patients are usually told to take a missed dose the same day if they remember, or skip it and record it, then seek advice. Regular INR checks, telling other clinicians and checking interactions are correct.

答案

A · "If I miss a dose, I will take two the next day."
11.内外科护理：神经、内分泌与肾脏

答案: D · Alcohol can cause hypos, even the next day, so eat carbs with it

为什么是这个答案

Alcohol reduces the liver's release of glucose, so it increases the risk of hypoglycaemia, which may be delayed for many hours. Patients should eat carbohydrate, check glucose before bed and tell friends that a hypo can look like drunkenness.

答案

D · Alcohol can cause hypos, even the next day, so eat carbs with it
12.内外科护理：神经、内分泌与肾脏

答案: C · IV calcium gluconate

为什么是这个答案

ECG changes mean the heart is at risk. IV calcium is given first to stabilise the myocardium, followed by insulin with glucose (and often nebulised salbutamol) to shift potassium into cells. Binders or dialysis then remove it.

答案

C · IV calcium gluconate
13.内外科护理：消化、围手术期与肿瘤

答案: C · 低钾血症

为什么是这个答案

低钾损害平滑肌收缩，是肠梗阻常见的可纠正促成因素。还应检查并纠正镁和其他电解质。

答案

C · 低钾血症
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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