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 patient with asthma has two inhalers: a corticosteroid and salbutamol (albuterol). Which statement shows a need for further teaching?

  1. A“I will carry my salbutamol inhaler with me.”
  2. B“I will use my steroid inhaler when I have a sudden attack.”
  3. C“I will rinse my mouth after using the steroid inhaler.”
  4. D“I will use my steroid inhaler every day, even when I feel well.”
2.优先排序与委派困难

护士应对哪位患者的计划出院提出质疑？

  1. A术后两天，新出现心率 112 次/分、体温 38.4 °C 的患者
  2. B石膏稳定、能用拐杖安全行走的患者
  3. C疝修补术后，已排尿并进食的患者
  4. D肺炎患者，口服抗生素后已 48 小时无发热
3.感染控制与患者安全中等

A patient in bed has a generalized tonic-clonic seizure. What should the nurse do?

  1. APut a padded tongue blade between the teeth to protect the tongue from biting
  2. BHold the arms and legs firmly to stop the movements
  3. CTurn the patient on their side and protect them from injury without restraining
  4. DGive sips of water to keep the airway moist
4.感染控制与患者安全困难

A nurse teaches a patient with active pulmonary tuberculosis who is going home on treatment. Which statement shows a need for further teaching?

  1. A“I will come back for sputum tests as planned.”
  2. B“I will need to take my medicines for several months.”
  3. C“I will cover my mouth with a tissue when I cough.”
  4. D“I can stop taking the pills once I feel better.”
5.实验室检查值与电解质中等

A week after a splenectomy, a patient's platelet count is 650 × 10³/µL. What is the best interpretation?

  1. AA laboratory error, because platelets fall after splenectomy
  2. BA sign of new leukemia that needs immediate chemotherapy
  3. CAn expected rise after splenectomy that increases clot risk
  4. DA sign of iron overload from the surgery and transfusion
6.实验室检查值与电解质困难

An RN cares for a patient on a 24-hour urine collection. Which task can be delegated to unlicensed assistive personnel (UAP), such as a nursing or healthcare assistant?

  1. AInterpreting the creatinine clearance result when it comes back
  2. BDeciding whether to restart the collection after a missed sample
  3. CSaving all urine in the collection container as instructed
  4. DTeaching the patient why the 24-hour collection is needed
7.临床护理中等

After a needlestick injury from a patient known to have HIV, why must the nurse report it immediately?

  1. AThe nurse must be tested for HIV the same day to confirm infection
  2. BThe needle must be sent for culture
  3. CPost-exposure prophylaxis works best when started as soon as possible
  4. DThe patient will need antibiotics
8.临床护理困难

A patient with myasthenia gravis develops increasing difficulty swallowing and weak, shallow breathing. What is the main danger?

  1. AA urinary tract infection
  2. BSevere hypertension from anxiety
  3. CRespiratory failure from a myasthenic crisis
  4. DA sudden rise in blood glucose from the stress
9.内外科护理：心血管与呼吸中等

哪项建议有助于预防长途飞行或手术后的 DVT？

  1. A定期做踝关节运动并摄入足够的液体
  2. B在膝盖下方戴紧的松紧带
  3. C少喝水，以免起身上厕所
  4. D为了舒适翘着二郎腿坐
10.内外科护理：心血管与呼吸困难

一名昨天开始服用 ACE 抑制剂的患者出现嘴唇和舌头肿胀以及声音嘶哑。护士首先应做什么？

  1. A评估气道，呼叫紧急援助，并暂停后续剂量
  2. B在嘴唇上敷冰，明早再评估
  3. C解释这是预期的、无害的副作用
  4. D提前给下一剂药，这样肿胀会很快消退
11.内外科护理：神经、内分泌与肾脏中等

一名服用卡比马唑治疗甲状腺功能亢进的患者主诉咽痛和发热。护士应怎么做？

  1. A建议用盐水漱口，并继续服药一周
  2. B安慰患者，因为该药没有严重的血液副作用
  3. C安排紧急全血细胞计数，排查粒细胞缺乏症
  4. D将剂量加倍，以更快控制甲状腺
12.内外科护理：神经、内分泌与肾脏困难

A patient's glucose is 6.2 mmol/L (112 mg/dL) at 03:00 and 12 mmol/L (216 mg/dL) before breakfast. No hypoglycaemia occurred overnight. What is the most likely explanation?

  1. AThe dawn phenomenon from early-morning hormones
  2. BThe meter is faulty and should be replaced
  3. CThe Somogyi effect from a night-time hypo
  4. DA large snack eaten in the night by mistake
13.内外科护理：消化、围手术期与肿瘤中等

当使用阿片类药物的患者镇静程度加深时，为什么这很重要？

  1. A镇静是所有阿片类药物无害且预期的作用
  2. B镇静加深通常先于呼吸抑制出现
  3. C镇静意味着现在需要更高的剂量
  4. D镇静意味着疼痛已得到完全、安全的控制
14.内外科护理：消化、围手术期与肿瘤困难

A patient has an implanted port for chemotherapy. Which needle is used to access it?

  1. AA standard hollow needle used for venepuncture
  2. BAn intramuscular injection needle
  3. CA non-coring (Huber) needle
  4. DA wide-bore cannula with a steel stylet

3溶液

1.优先排序与委派

答案: B · “I will use my steroid inhaler when I have a sudden attack.”

为什么是这个答案

Inhaled corticosteroids reduce inflammation over time and do not relieve an acute attack. Salbutamol (albuterol) is the quick-relief inhaler; rinsing after steroids helps prevent oral thrush.

答案

B · “I will use my steroid inhaler when I have a sudden attack.”
2.优先排序与委派

答案: A · 术后两天，新出现心率 112 次/分、体温 38.4 °C 的患者

为什么是这个答案

术后新出现发热和心动过速可能提示感染或其他并发症，因此护士在出院前应评估并提出该问题。其他患者是稳定的，达到了预期目标。

答案

A · 术后两天，新出现心率 112 次/分、体温 38.4 °C 的患者
3.感染控制与患者安全

答案: C · Turn the patient on their side and protect them from injury without restraining

为什么是这个答案

The nurse stays with the patient, turns them to the side to keep the airway clear, moves hard objects away and times the seizure. Objects in the mouth and restraint can cause injury.

答案

C · Turn the patient on their side and protect them from injury without restraining
4.感染控制与患者安全

答案: D · “I can stop taking the pills once I feel better.”

为什么是这个答案

TB treatment lasts several months, and stopping when symptoms improve can lead to relapse and drug-resistant TB. Covering coughs and attending follow-up for sputum tests are correct.

答案

D · “I can stop taking the pills once I feel better.”
5.实验室检查值与电解质

答案: C · An expected rise after splenectomy that increases clot risk

为什么是这个答案

The spleen stores about a third of the platelets. After splenectomy, the count often rises (reactive thrombocytosis), which can increase the risk of thrombosis. The count is monitored, and the patient is assessed for signs of clots.核对依据: Platelet count · MedlinePlus (NIH) (2025); Platelet Tests · MedlinePlus (NIH) (2024)

答案

C · An expected rise after splenectomy that increases clot risk
6.实验室检查值与电解质

答案: C · Saving all urine in the collection container as instructed

为什么是这个答案

UAP can help with routine, standard tasks such as saving urine and keeping the container cool as instructed. Teaching, clinical decisions and interpreting results require nursing judgment and stay with the RN.核对依据: 24-Hour Urine Collection and Analysis · StatPearls (NCBI Bookshelf) (2024)

答案

C · Saving all urine in the collection container as instructed
7.临床护理

答案: C · Post-exposure prophylaxis works best when started as soon as possible

为什么是这个答案

HIV post-exposure prophylaxis should be started as soon as possible after exposure, ideally within hours. Occupational health or the emergency department will assess the risk and arrange follow-up testing.

答案

C · Post-exposure prophylaxis works best when started as soon as possible
8.临床护理

答案: C · Respiratory failure from a myasthenic crisis

为什么是这个答案

In a myasthenic crisis, weakness of respiratory and bulbar muscles can cause aspiration and respiratory failure. Breathing function is monitored closely and ventilation may be needed.

答案

C · Respiratory failure from a myasthenic crisis
9.内外科护理：心血管与呼吸

答案: A · 定期做踝关节运动并摄入足够的液体

为什么是这个答案

小腿肌肉活动、补充水分，以及在有指征时使用合适的加压弹力袜或药物预防，可减少静脉淤滞和血栓形成。翘腿和紧的束带会妨碍静脉回流，而脱水会增加血液黏稠度。

答案

A · 定期做踝关节运动并摄入足够的液体
10.内外科护理：心血管与呼吸

答案: A · 评估气道，呼叫紧急援助，并暂停后续剂量

为什么是这个答案

血管性水肿是 ACE 抑制剂罕见但可能危及生命的反应，由缓激肽蓄积引起。优先处理气道受损：呼叫紧急援助，密切监测气道和呼吸，并永久停药。即使用药多年后也可能发生。

答案

A · 评估气道，呼叫紧急援助，并暂停后续剂量
11.内外科护理：神经、内分泌与肾脏

答案: C · 安排紧急全血细胞计数，排查粒细胞缺乏症

为什么是这个答案

硫脲类药物（卡比马唑、甲巯咪唑、丙硫氧嘧啶）可引起粒细胞缺乏症，这是一种罕见但危及生命的中性粒细胞下降。应教导患者立即报告咽痛、发热或口腔溃疡，并紧急检查血常规；如果中性粒细胞偏低则停药。

答案

C · 安排紧急全血细胞计数，排查粒细胞缺乏症
12.内外科护理：神经、内分泌与肾脏

答案: A · The dawn phenomenon from early-morning hormones

为什么是这个答案

In the dawn phenomenon, cortisol and growth hormone rise in the early morning and push glucose up without a preceding hypo. A night-time hypo followed by rebound hyperglycaemia would suggest the Somogyi effect. The prescriber can adjust the insulin regimen.

答案

A · The dawn phenomenon from early-morning hormones
13.内外科护理：消化、围手术期与肿瘤

答案: B · 镇静加深通常先于呼吸抑制出现

为什么是这个答案

镇静评分常在呼吸频率下降之前就恶化。监测镇静程度（例如使用镇静量表）以及呼吸频率和血氧饱和度，有助于及早发现阿片类药物中毒。镇静加深意味着应暂停下一剂并复评患者。

答案

B · 镇静加深通常先于呼吸抑制出现
14.内外科护理：消化、围手术期与肿瘤

答案: C · A non-coring (Huber) needle

为什么是这个答案

Implanted ports have a silicone septum that reseals after access with a non-coring needle. Aseptic technique, checking blood return before use and flushing according to policy keep the device working safely.

答案

C · A non-coring (Huber) needle

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