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。

新题目返回课程

在打印窗口中选择“另存为 PDF”，即可在设备上保存一份副本。

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 anxious patient is breathing very fast and has tingling fingers. The blood gas shows pH 7.51 and PaCO₂ 29 mmHg (3.9 kPa). What should the nurse do first?

  1. AGive IV sodium bicarbonate as soon as it can be found
  2. BStay with the patient and coach slow, calm breathing
  3. CEncourage the patient to breathe even faster
  4. DGive oxygen at the highest flow and leave the room
2.优先排序与委派困难

An RN sees an LPN/LVN crushing an extended-release metoprolol tablet to mix with applesauce. What should the RN do?

  1. ALet the LPN/LVN continue, since crushing makes the tablet easier to swallow
  2. BStop the LPN/LVN and contact the prescriber or pharmacist about another form
  3. CReport the LPN/LVN at the end of the month without saying anything now
  4. DTell the LPN/LVN to give half of the crushed tablet now and the other half at lunchtime
3.感染控制与患者安全中等

Which drugs are used as antidotes for nerve agent poisoning?

  1. AAtropine and pralidoxime
  2. BNaloxone and flumazenil
  3. CAcetylcysteine and charcoal
  4. DVitamin K and protamine
4.感染控制与患者安全困难

A nurse has raised a safety concern about an order with the prescriber, who dismissed it without addressing it. What should the nurse do next?

  1. ADiscuss the concern with the patient and let them decide
  2. BCarry out the order as written, because the prescriber has heard the concern
  3. CRefuse to care for the patient for the rest of the shift until the prescriber apologizes
  4. DState the concern clearly a second time and, if still unresolved, use the chain of command
5.实验室检查值与电解质中等

万古霉素谷浓度高于目标范围。主要担忧是哪种不良反应？

  1. A便秘和腹胀
  2. B低血糖
  3. C肾损害（肾毒性）
  4. D血小板计数升高（血小板增多症）
6.实验室检查值与电解质困难

A patient with acute pancreatitis has a rising BUN, a falling calcium and a glucose of 250 mg/dL (13.9 mmol/L) over the first 48 hours. What do these results suggest?

  1. AA lab error from lipemic samples
  2. BAn unrelated new kidney stone
  3. CIncreasingly severe pancreatitis
  4. DA resolving, mild pancreatitis
7.临床护理中等

How does ulcerative colitis differ from Crohn's disease?

  1. AUlcerative colitis typically causes patchy "skip" lesions
  2. BUlcerative colitis always affects the full thickness of the bowel wall
  3. CUlcerative colitis can affect any part of the gut from mouth to anus
  4. DUlcerative colitis affects only the colon, continuously from the rectum
8.临床护理困难

一名患者的血液检查显示血钾 6.8 mmol/L，心电图显示 T 波高尖。哪种治疗能最快地保护心脏？

  1. A口服补钾
  2. B仅采用低钾饮食
  3. C静脉注射葡萄糖酸钙
  4. D第二天口服呋塞米片
9.内外科护理：心血管与呼吸中等

Which foot care advice is correct for a patient with peripheral arterial disease?

  1. AUse a hot water bottle on the feet at night
  2. BCheck the feet daily and wear well-fitting shoes
  3. CWalk barefoot at home to strengthen the feet
  4. DCut corns with a razor blade to prevent pressure
10.内外科护理：心血管与呼吸困难

Three days after an MI, a patient faints on the commode while straining hard to open the bowels. The heart rate was 42/min at the time. What is the most likely mechanism?

  1. AA new pulmonary embolism
  2. BLow blood glucose from fasting
  3. CA vagal response to straining
  4. DAn allergic reaction to the commode
11.内外科护理：神经、内分泌与肾脏中等

Which side effects are common with oxybutynin for an overactive bladder?

  1. ADry mouth and constipation
  2. BWeight loss and a fast tremor
  3. CDiarrhoea and heavy sweating
  4. DA cough and a raised potassium
12.内外科护理：神经、内分泌与肾脏困难

A patient has had a high sodium of 160 mmol/L for several days. Why must it be corrected slowly?

  1. ARapid correction can cause brain swelling
  2. BThe sodium will rise again if corrected quickly
  3. CRapid correction causes kidney stones
  4. DRapid correction raises the blood glucose
13.内外科护理：消化、围手术期与肿瘤中等

为什么教患者咳嗽时用枕头支托腹部伤口？

  1. A它可减轻疼痛和牵拉，使患者能有效咳嗽
  2. B它取代了规律镇痛的需要
  3. C它加速皮肤边缘的愈合
  4. D它使咳嗽变弱，从而不使伤口受到风险
14.内外科护理：消化、围手术期与肿瘤困难

A patient with advanced cancer who has capacity decides to stop chemotherapy. The family insists that treatment must continue. What should the nurse do?

  1. AContinue treatment because the family has asked for it
  2. BTell the patient that stopping is not allowed
  3. CAsk the family to sign a new consent form
  4. DSupport the patient's decision and help the team talk with the family

3溶液

1.优先排序与委派

答案: B · Stay with the patient and coach slow, calm breathing

为什么是这个答案

These results show respiratory alkalosis caused by hyperventilation. Calming the patient and coaching slower breathing lets carbon dioxide return to normal; the nurse also looks for physical causes.

答案

B · Stay with the patient and coach slow, calm breathing
2.优先排序与委派

答案: B · Stop the LPN/LVN and contact the prescriber or pharmacist about another form

为什么是这个答案

Crushing an extended-release tablet releases the whole dose at once and can cause toxicity, such as severe bradycardia or hypotension. The RN steps in now and arranges a suitable form.

答案

B · Stop the LPN/LVN and contact the prescriber or pharmacist about another form
3.感染控制与患者安全

答案: A · Atropine and pralidoxime

为什么是这个答案

Nerve agents inhibit acetylcholinesterase, causing excess acetylcholine. Atropine blocks muscarinic effects such as secretions and bradycardia, and pralidoxime helps to reactivate the enzyme.

答案

A · Atropine and pralidoxime
4.感染控制与患者安全

答案: D · State the concern clearly a second time and, if still unresolved, use the chain of command

为什么是这个答案

The two-challenge rule says the concern is voiced at least twice to make sure it was heard. If it is still not addressed, the nurse escalates through the chain of command rather than acting against the patient’s safety.

答案

D · State the concern clearly a second time and, if still unresolved, use the chain of command
5.实验室检查值与电解质

答案: C · 肾损害（肾毒性）

为什么是这个答案

万古霉素水平高与急性肾损伤以及较少见的听力损害有关。护士应在下一次给药前报告结果，并检查肌酐和尿量。

答案

C · 肾损害（肾毒性）
6.实验室检查值与电解质

答案: C · Increasingly severe pancreatitis

为什么是这个答案

Rising BUN (fluid loss and kidney injury), low calcium and hyperglycemia are markers of more severe pancreatitis in scoring systems. The nurse monitors fluid balance, vital signs and organ function closely and reports deterioration.

答案

C · Increasingly severe pancreatitis
7.临床护理

答案: D · Ulcerative colitis affects only the colon, continuously from the rectum

为什么是这个答案

Ulcerative colitis involves the mucosa of the colon, spreading continuously from the rectum. Crohn's disease can affect any part of the GI tract, is transmural and has skip lesions.

答案

D · Ulcerative colitis affects only the colon, continuously from the rectum
8.临床护理

答案: C · 静脉注射葡萄糖酸钙

为什么是这个答案

静脉注射钙剂可在数分钟内稳定心肌。随后用胰岛素加葡萄糖使钾转移到细胞内，再用其他措施将钾排出体外。

答案

C · 静脉注射葡萄糖酸钙
9.内外科护理：心血管与呼吸

答案: B · Check the feet daily and wear well-fitting shoes

为什么是这个答案

Reduced blood flow slows healing, so minor injuries can become ulcers or gangrene. Patients inspect their feet daily, keep them clean and moisturised, wear well-fitting footwear and see a podiatrist for nails and corns. Direct heat can burn ischaemic skin.

答案

B · Check the feet daily and wear well-fitting shoes
10.内外科护理：心血管与呼吸

答案: C · A vagal response to straining

为什么是这个答案

Straining (the Valsalva manoeuvre) can cause a vagal bradycardia and a fall in cardiac output, leading to syncope. After an MI, stool softeners, adequate fluids and avoiding straining are advised. The event is still reported and the patient assessed for arrhythmia or ischaemia.

答案

C · A vagal response to straining
11.内外科护理：神经、内分泌与肾脏

答案: A · Dry mouth and constipation

为什么是这个答案

Oxybutynin blocks muscarinic receptors, causing dry mouth, constipation, blurred vision, urinary retention and, especially in older adults, confusion. Newer agents may have fewer effects on the brain.

答案

A · Dry mouth and constipation
12.内外科护理：神经、内分泌与肾脏

答案: A · Rapid correction can cause brain swelling

为什么是这个答案

In chronic hypernatraemia, brain cells adapt by holding extra solutes. If the sodium falls too quickly, water rushes into the cells and causes cerebral oedema and seizures. Correction is gradual, with regular sodium checks.

答案

A · Rapid correction can cause brain swelling
13.内外科护理：消化、围手术期与肿瘤

答案: A · 它可减轻疼痛和牵拉，使患者能有效咳嗽

为什么是这个答案

支托切口可减轻疼痛和对伤口的压力，使患者能够深呼吸和有效咳嗽，以清除分泌物并预防胸部感染。同时还需要充分的镇痛。

答案

A · 它可减轻疼痛和牵拉，使患者能有效咳嗽
14.内外科护理：消化、围手术期与肿瘤

答案: D · Support the patient's decision and help the team talk with the family

为什么是这个答案

A competent adult can refuse treatment. The nurse advocates for the patient, supports communication with the family and team, and helps plan symptom control and palliative care.

答案

D · Support the patient's decision and help the team talk with the family

ExamProblems · examproblems.com/courses/nclex-style-prioritization-and-delegation