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 patient who has been constipated for days now has small amounts of liquid stool leaking. What should the nurse suspect?

  1. AThe constipation has fully resolved
  2. BA new bowel infection that has caused the diarrhea
  3. CFecal impaction with liquid stool passing around it
  4. DA side effect of drinking too much water
2.优先排序与委派困难

A patient has central chest pain that started 30 minutes ago at rest and has not eased with rest or nitroglycerin. What does this suggest?

  1. AMuscle strain that needs a warm compress
  2. BA possible myocardial infarction that needs urgent action
  3. CStable angina that will pass without treatment
  4. DIndigestion that is best treated with an antacid and a glass of milk
3.感染控制与患者安全中等

Where is a gait belt placed when helping a patient to walk?

  1. AAround the patient’s waist, over clothing
  2. BAround both thighs, just above the knees
  3. CAround the hips, directly on bare skin
  4. DAround the chest, under the arms
4.感染控制与患者安全困难

一名患有唇疱疹（herpes labialis）的护士被分配到新生儿室。最恰当的做法是什么？

  1. A不告诉任何人，上班时用化妆品遮住皮损
  2. B照常工作，因为唇疱疹很常见
  3. C告知主管，主管可能暂时调整其工作安排
  4. D戴上手套，照常工作
5.实验室检查值与电解质中等

一名患者的左前臂正在输注静脉液体。护士应在何处采集血样？

  1. A在输液进行时从静脉套管采集
  2. B同一手臂上静脉输液部位的稍上方
  3. C任何静脉均可，因为液体不影响结果
  4. D对侧手臂
6.实验室检查值与电解质困难

A patient without diabetes in the ICU with sepsis has a glucose of 260 mg/dL (14.4 mmol/L) and an HbA1c of 5.2%. What is the best interpretation?

  1. AA meter error, because HbA1c is normal
  2. BType 1 diabetes from autoimmune damage
  3. CStress hyperglycemia from acute illness
  4. DLong-standing undiagnosed type 2 diabetes
7.临床护理中等

Which pattern is typical of relapsing–remitting multiple sclerosis?

  1. ASudden severe headache with neck stiffness
  2. BAttacks of symptoms, such as visual loss or numbness, that improve between relapses
  3. CA single stroke that leaves permanent weakness
  4. DConstant weakness that starts in the feet and spreads upwards after a viral illness
8.临床护理困难

一名头部外伤患者出现血压升高、心率减慢和呼吸不规则。这提示：

  1. A隐匿性内出血引起的低血容量性休克
  2. B颅内压增高（库欣三联征）
  3. C脓毒症
  4. D惊恐发作
9.内外科护理：心血管与呼吸中等

How big should a suction catheter be compared with the tracheostomy or endotracheal tube?

  1. ALarger than the tube, so that it clears it completely
  2. BAny size, as the diameter does not matter
  3. CNo more than half the internal diameter of the tube
  4. DExactly the same diameter as the tube, for a tight fit
10.内外科护理：心血管与呼吸困难

为什么高流量氧疗要使用湿化？

  1. A高流量的干燥气体会使气道干燥，分泌物变稠
  2. B湿化可防止氧中毒的发生
  3. C水蒸气可滤除氧气供应中的细菌
  4. D湿化的气体每升携带的氧气比干燥气体多
11.内外科护理：神经、内分泌与肾脏中等

A kidney transplant recipient asks about travel vaccines. Which statement is correct?

  1. AVaccines will cause the kidney to be rejected
  2. BOnly live vaccines are effective after a transplant
  3. CAll vaccines are completely safe after a transplant
  4. DLive vaccines are usually avoided
12.内外科护理：神经、内分泌与肾脏困难

During a water deprivation test for suspected diabetes insipidus, the patient loses more than 3% of body weight and becomes hypotensive. What should the nurse do?

  1. AGive desmopressin without a prescription
  2. BContinue the test, because this result is expected
  3. CStop the test and inform the doctor
  4. DGive the patient a large drink and then restart the test
13.内外科护理：消化、围手术期与肿瘤中等

Why are patients with diabetes often placed early on the operating list?

  1. ABecause their surgery always takes longer than others
  2. BBecause their wounds heal faster in the morning
  3. CTo shorten fasting and reduce swings in blood glucose
  4. DBecause they need to go home before midday
14.内外科护理：消化、围手术期与肿瘤困难

Two days after a PEG insertion, a patient reports pain on feeding, and feed is leaking around the site. What should the nurse do?

  1. AContinue feeding and apply a thicker dressing
  2. BIncrease the feed rate to improve nutrition
  3. CStop the feed at once and seek urgent medical advice
  4. DGive the next medicines through the tube as usual

3溶液

1.优先排序与委派

答案: C · Fecal impaction with liquid stool passing around it

为什么是这个答案

In fecal impaction, liquid stool from higher in the bowel leaks around the hard mass. Giving an antidiarrheal would make things worse; the nurse assesses and reports.

答案

C · Fecal impaction with liquid stool passing around it
2.优先排序与委派

答案: B · A possible myocardial infarction that needs urgent action

为什么是这个答案

Chest pain that lasts and is not relieved by rest or nitroglycerin suggests acute coronary syndrome, possibly a heart attack. The nurse acts at once: ECG, escalation and prescribed treatment.

答案

B · A possible myocardial infarction that needs urgent action
3.感染控制与患者安全

答案: A · Around the patient’s waist, over clothing

为什么是这个答案

The gait belt goes snugly around the waist over clothing, close to the center of gravity, with room for the nurse’s fingers underneath. Holding it gives control without pulling on the arms.

答案

A · Around the patient’s waist, over clothing
4.感染控制与患者安全

答案: C · 告知主管，主管可能暂时调整其工作安排

为什么是这个答案

单纯疱疹病毒可在新生儿中引起严重感染。有活动性皮损的工作人员应告知主管并遵循职业健康建议，这通常意味着在皮损愈合前避免接触新生儿和其他高危患者。

答案

C · 告知主管，主管可能暂时调整其工作安排
5.实验室检查值与电解质

答案: D · 对侧手臂

为什么是这个答案

在正在输液处附近采集的血液会与静脉液体混合，导致葡萄糖偏高或血红蛋白偏低等错误结果。应从另一只手臂采血，如不可能，则按规定处理。

答案

D · 对侧手臂
6.实验室检查值与电解质

答案: C · Stress hyperglycemia from acute illness

为什么是这个答案

Stress hormones and inflammation raise glucose in acute illness, even without diabetes. A normal HbA1c shows that glucose was normal over the previous months. Stress hyperglycemia is still treated, usually with insulin, because it worsens outcomes.核对依据: Hemoglobin A1C (HbA1c) Test · MedlinePlus (NIH) (2025)

答案

C · Stress hyperglycemia from acute illness
7.临床护理

答案: B · Attacks of symptoms, such as visual loss or numbness, that improve between relapses

为什么是这个答案

MS causes demyelination in the brain and spinal cord. Many patients first have attacks such as optic neuritis or sensory symptoms, with partial or full recovery between relapses.

答案

B · Attacks of symptoms, such as visual loss or numbness, that improve between relapses
8.临床护理

答案: B · 颅内压增高（库欣三联征）

为什么是这个答案

库欣三联征（高血压伴脉压增大、心动过缓和呼吸不规则）是颅内压增高的晚期征象，需要紧急处理。

答案

B · 颅内压增高（库欣三联征）
9.内外科护理：心血管与呼吸

答案: C · No more than half the internal diameter of the tube

为什么是这个答案

A catheter no larger than half the internal diameter of the tube lets air enter around it, reducing negative pressure in the lungs, atelectasis and hypoxaemia. Catheter size is often calculated from the tube size.

答案

C · No more than half the internal diameter of the tube
10.内外科护理：心血管与呼吸

答案: A · 高流量的干燥气体会使气道干燥，分泌物变稠

为什么是这个答案

高流量干燥气体超出了鼻腔湿化的能力，导致黏膜干燥、分泌物变稠和不适。加温加湿的高流量系统可提高耐受性并帮助清除分泌物。

答案

A · 高流量的干燥气体会使气道干燥，分泌物变稠
11.内外科护理：神经、内分泌与肾脏

答案: D · Live vaccines are usually avoided

为什么是这个答案

Live vaccines, such as yellow fever, can cause infection in immunosuppressed patients and are usually avoided. Inactivated vaccines, such as influenza, are recommended, although the response may be weaker.

答案

D · Live vaccines are usually avoided
12.内外科护理：神经、内分泌与肾脏

答案: C · Stop the test and inform the doctor

为什么是这个答案

In DI, the patient keeps passing dilute urine despite fluid restriction and can become dangerously dehydrated. Significant weight loss, hypotension or a high sodium are reasons to stop the test and get medical review.

答案

C · Stop the test and inform the doctor
13.内外科护理：消化、围手术期与肿瘤

答案: C · To shorten fasting and reduce swings in blood glucose

为什么是这个答案

Shorter fasting reduces the risk of hypoglycaemia and makes it easier to restart normal eating and medicines. Glucose is monitored, and a variable-rate insulin infusion may be used for longer fasts.

答案

C · To shorten fasting and reduce swings in blood glucose
14.内外科护理：消化、围手术期与肿瘤

答案: C · Stop the feed at once and seek urgent medical advice

为什么是这个答案

Pain on feeding, external leakage or new bleeding soon after PEG insertion may mean feed is leaking into the peritoneum. Feeding and medicines are stopped immediately and senior review is arranged to exclude peritonitis.

答案

C · Stop the feed at once and seek urgent medical advice

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