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

An older adult asks for something to help them sleep. Which drug is most likely to cause confusion and falls in this age group?

  1. AA warm milky drink
  2. BAcetaminophen (paracetamol)
  3. CMelatonin
  4. DDiphenhydramine
2.优先排序与委派困难

A patient suddenly has severe pain in one leg. The leg is pale and cold with no pedal pulse. What does this suggest?

  1. AChronic venous insufficiency that needs elevation
  2. BA muscle cramp that will pass with stretching
  3. CA deep vein thrombosis that can be treated next week
  4. DAcute arterial occlusion, which is an emergency
3.感染控制与患者安全中等

A nurse cleans an IV pump with a disinfectant wipe. What must happen for the disinfectant to work?

  1. AThe surface is dried with a clean towel right after wiping
  2. BThe surface is wiped once lightly without pressure
  3. CThe wipe is used on many pumps to save product
  4. DThe surface stays wet for the contact time on the product label
4.感染控制与患者安全困难

The laboratory reports that a blood sample labeled with one patient’s name has a blood group different from that patient’s previous result. What is the most likely problem and response?

  1. AA laboratory machine fault, so no action is needed
  2. BA normal change in the patient’s blood group over the years since the last test
  3. CA wrong-patient sample, so the test is repeated and the event reported
  4. DThe previous result was wrong, so it is deleted
5.实验室检查值与电解质中等

在慢性肾脏病中，血清磷酸盐升高通常伴有钙的哪种变化？

  1. A仅血清钾升高，钙无变化
  2. B钙无变化
  3. C血清钙升高
  4. D血清钙降低
6.实验室检查值与电解质困难

A middle-aged man has fatigue, joint pain, a raised ALT and new diabetes. His ferritin is very high and his transferrin saturation is above 60%. Which condition is most likely?

  1. AAnemia of chronic disease
  2. BHereditary hemochromatosis
  3. CAcute viral hepatitis A
  4. DIron-deficiency anemia
7.临床护理中等

HbA1c 测量的是什么？

  1. A大约过去两到三个月的平均血糖
  2. B检测时刻的血糖
  3. C尿中的酮体含量
  4. D餐后胰岛素水平
8.临床护理困难

After a viral illness, a patient has sharp chest pain that is worse lying flat and eased by sitting forward. What is the most likely cause?

  1. APulmonary oedema
  2. BAortic dissection
  3. CStable angina
  4. DPericarditis
9.内外科护理：心血管与呼吸中等

Which advice is most helpful for a patient with Raynaud's phenomenon?

  1. AKeep the whole body warm, wear gloves and stop smoking
  2. BSoak the hands in cold water to toughen the vessels
  3. CTake a decongestant tablet before going outdoors
  4. DRub the fingers hard with snow during an attack
10.内外科护理：心血管与呼吸困难

A patient receiving weeks of IV antibiotics through a PICC line in the left arm develops swelling and aching of that arm and neck veins that look fuller on the left. What should the nurse suspect?

  1. AA local skin allergy to the dressing
  2. BA catheter-related deep vein thrombosis
  3. CLymphoedema from lying in bed
  4. DAn expected effect of the antibiotic
11.内外科护理：神经、内分泌与肾脏中等

A patient with gout has recurrent uric acid kidney stones. Which treatment helps prevent them?

  1. AVitamin C supplements and a high-meat diet
  2. BCalcium tablets and a low-fluid diet
  3. CRestricting fluids in the evening only
  4. DAllopurinol and making the urine less acidic
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手术引起的 SIADH
  2. B静脉输液引起的液体过多
  3. C低血容量引起的肾前性 AKI
  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

What is a Curling's ulcer?

  1. AA stress ulcer of the stomach or duodenum after a major burn
  2. BA leg ulcer caused by venous disease after long bed rest
  3. CA burn on the sole of the foot
  4. DA pressure ulcer under a splint that has been left on too long
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. AOral aspirin to balance the clotting system quickly
  2. BMore warfarin to stabilise the INR
  3. CProthrombin complex concentrate with IV vitamin K
  4. DProtamine sulfate on its own

3溶液

1.优先排序与委派

答案: D · Diphenhydramine

为什么是这个答案

Diphenhydramine is strongly anticholinergic and can cause confusion, urinary retention and falls in older adults. It is on lists of drugs to avoid in this group.

答案

D · Diphenhydramine
2.优先排序与委派

答案: D · Acute arterial occlusion, which is an emergency

为什么是这个答案

Sudden pain, pallor, coldness and loss of pulse suggest an embolus blocking an artery. The limb can be lost within hours, so the nurse escalates immediately.

答案

D · Acute arterial occlusion, which is an emergency
3.感染控制与患者安全

答案: D · The surface stays wet for the contact time on the product label

为什么是这个答案

Each disinfectant has a contact (dwell) time during which the surface must stay visibly wet. Drying it early or spreading one wipe over many items reduces its effect.

答案

D · The surface stays wet for the contact time on the product label
4.感染控制与患者安全

答案: C · A wrong-patient sample, so the test is repeated and the event reported

为什么是这个答案

A different blood group strongly suggests the sample came from another patient. A new sample is taken with careful bedside identification and labeling, and the event is reported as a serious near miss.

答案

C · A wrong-patient sample, so the test is repeated and the event reported
5.实验室检查值与电解质

答案: D · 血清钙降低

为什么是这个答案

当衰竭的肾脏潴留磷酸盐时，磷酸盐与钙结合，维生素 D 的活化减少，因此血清钙倾向于下降。这会导致继发性甲状旁腺功能亢进和骨病。核对依据: Hypocalcemia (StatPearls) · StatPearls (NCBI Bookshelf) (2026); Phosphate in Blood · MedlinePlus (NIH) (2023)

答案

D · 血清钙降低
6.实验室检查值与电解质

答案: B · Hereditary hemochromatosis

为什么是这个答案

Hemochromatosis is an inherited disorder of increased iron absorption. Iron is deposited in the liver, pancreas, joints, heart and skin. A high transferrin saturation with a high ferritin suggests the diagnosis, and treatment is regular venesection (phlebotomy).核对依据: Hemochromatosis · MedlinePlus (NIH) (2026); Ferritin Blood Test · MedlinePlus (NIH) (2025)

答案

B · Hereditary hemochromatosis
7.临床护理

答案: A · 大约过去两到三个月的平均血糖

为什么是这个答案

HbA1c 反映红细胞生命周期内血红蛋白的糖化程度，可用来估计长期血糖控制情况。

答案

A · 大约过去两到三个月的平均血糖
8.临床护理

答案: D · Pericarditis

为什么是这个答案

Pericarditis typically causes sharp, positional chest pain relieved by sitting forward, sometimes with a pericardial rub. Viral infection is a common cause.

答案

D · Pericarditis
9.内外科护理：心血管与呼吸

答案: A · Keep the whole body warm, wear gloves and stop smoking

为什么是这个答案

Keeping the core and hands warm, wearing gloves and stopping smoking reduce attacks. Vasoconstrictors such as decongestants and nicotine make it worse. During an attack, gentle warming of the hands is advised.

答案

A · Keep the whole body warm, wear gloves and stop smoking
10.内外科护理：心血管与呼吸

答案: B · A catheter-related deep vein thrombosis

为什么是这个答案

Upper-limb DVT is a recognised complication of PICCs and other central lines. Arm swelling, pain and distended veins should be reported, and an ultrasound arranged. The line is not flushed forcefully, and treatment usually involves anticoagulation.

答案

B · A catheter-related deep vein thrombosis
11.内外科护理：神经、内分泌与肾脏

答案: D · Allopurinol and making the urine less acidic

为什么是这个答案

Uric acid stones form when urine is acidic and rich in uric acid. High fluid intake, alkalinising the urine (for example with potassium citrate) and allopurinol reduce the risk. Purine-rich foods are limited.

答案

D · Allopurinol and making the urine less acidic
12.内外科护理：神经、内分泌与肾脏

答案: C · 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

C · 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: A · A stress ulcer of the stomach or duodenum after a major burn

为什么是这个答案

Curling's ulcer is an acute peptic ulcer after severe burns, linked with reduced gut blood flow. Early enteral feeding and acid suppression help prevent it, and GI bleeding is watched for.

答案

A · A stress ulcer of the stomach or duodenum after a major burn
14.内外科护理：消化、围手术期与肿瘤

答案: C · 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

C · Prothrombin complex concentrate with IV vitamin K

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