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

Which telephone call should a clinic nurse return first?

  1. AA parent of a 5-year-old with a runny nose for two days
  2. BA parent of a 6-week-old with a temperature of 38.3 °C
  3. CAn adult asking for a repeat prescription for a statin
  4. DAn adult who wants to move a routine blood test appointment
2.优先排序与委派困难

An infant with pyloric stenosis has repeated projectile vomiting. Which acid-base imbalance is most likely?

  1. AMetabolic alkalosis
  2. BRespiratory acidosis
  3. CMetabolic acidosis
  4. DRespiratory alkalosis
3.感染控制与患者安全中等

Which drugs are used as antidotes for nerve agent poisoning?

  1. AVitamin K and protamine
  2. BNaloxone and flumazenil
  3. CAtropine and pralidoxime
  4. DAcetylcysteine and charcoal
4.感染控制与患者安全困难

A nurse notices that the pharmacy has sent the wrong dose and corrects it before giving it. Should the event be reported?

  1. AYes, near misses are reported so system weaknesses can be fixed
  2. BNo, because the patient was not harmed
  3. CNo, because reporting near misses only blames the pharmacy staff for nothing
  4. DOnly if the same error happens three times
5.实验室检查值与电解质中等

A patient without symptoms has a fasting plasma glucose of 132 mg/dL (7.3 mmol/L) on Monday and 138 mg/dL (7.7 mmol/L) on Thursday. What does this show?

  1. AThe results are within the normal fasting range
  2. BThe results show prediabetes only
  3. CThe results meet the criteria for diabetes
  4. DThe results show reactive hypoglycemia
6.实验室检查值与电解质困难

一名转移性乳腺癌患者钙为 13.2 mg/dL（3.3 mmol/L），意识模糊并便秘。护士预期会首先开始哪种处方治疗？

  1. A口服钙补充剂
  2. B严格卧床休息
  3. C静脉输注 0.9% 氯化钠
  4. D噻嗪类利尿剂
7.临床护理中等

Under the Mental Capacity Act 2005 (England and Wales), which principle applies?

  1. AA person must be assumed to have capacity unless it is shown that they lack it
  2. BCapacity is decided by the next of kin, who must sign a form for every decision
  3. CEveryone over 75 is assumed to lack capacity
  4. DA diagnosis of dementia means the person lacks capacity for all decisions
8.临床护理困难

A patient with known cirrhosis suddenly vomits large amounts of bright red blood and becomes tachycardic. What is the most likely cause?

  1. ASwallowed blood from a nosebleed
  2. BBleeding from ruptured oesophageal varices
  3. CA Mallory-Weiss tear from a small amount of vomiting
  4. DA lower GI bleed from diverticular disease
9.内外科护理：心血管与呼吸中等

A nurse measures blood pressure on a large upper arm using a cuff that is too small. What effect will this have?

  1. AThe reading will be falsely high
  2. BOnly the pulse rate will be affected
  3. CThe reading will be accurate but slower
  4. DThe reading will be falsely low
10.内外科护理：心血管与呼吸困难

Two days after a coronary stent, a patient on aspirin and ticagrelor has black, tarry stools and feels faint on standing. What should the nurse do?

  1. ACheck vital signs, report urgently and anticipate a blood count
  2. BGive a laxative and repeat the observations tomorrow
  3. CReassure the patient that iron tablets cause black stools
  4. DStop both antiplatelet drugs permanently on the nurse's own decision
11.内外科护理：神经、内分泌与肾脏中等

A patient has confirmed meningococcal meningitis. What is usually offered to their close household contacts?

  1. APreventive antibiotics
  2. BA lumbar puncture to check for infection
  3. CNo action unless they develop symptoms
  4. DA full course of IV antibiotics in hospital
12.内外科护理：神经、内分泌与肾脏困难

A patient with a subarachnoid haemorrhage develops a low sodium. Why is fluid restriction usually avoided in this patient?

  1. ALow sodium in this condition always corrects itself
  2. BFluid restriction would cause the aneurysm to re-bleed
  3. CFluid restriction raises the risk of seizures
  4. DLow blood volume can worsen vasospasm and brain ischaemia
13.内外科护理：消化、围手术期与肿瘤中等

Why is a gastrostomy tube with an internal bumper usually advanced and rotated regularly once the tract has healed?

  1. ATo stop the inner bumper becoming buried in the stomach wall
  2. BTo make the tube longer as the patient grows or gains weight
  3. CTo remove any feed left in the stomach
  4. DTo check that the patient is still hungry
14.内外科护理：消化、围手术期与肿瘤困难

During a nasogastric feed, a patient starts coughing and SpO₂ falls from 96% to 89%. What should the nurse do first?

  1. AGive a drink of water to clear the throat
  2. BStop the feed and assess the airway and breathing
  3. CIncrease the feed rate to finish it sooner
  4. DLay the patient flat to help them rest

3溶液

1.优先排序与委派

答案: B · A parent of a 6-week-old with a temperature of 38.3 °C

为什么是这个答案

A fever in an infant under about 3 months old needs urgent assessment, because serious bacterial infection is more likely and signs can be subtle. The other calls are routine.

答案

B · A parent of a 6-week-old with a temperature of 38.3 °C
2.优先排序与委派

答案: A · Metabolic alkalosis

为什么是这个答案

Repeated vomiting of stomach contents loses hydrochloric acid, causing metabolic alkalosis, often with low chloride and potassium. Fluids and electrolytes are corrected before surgery.

答案

A · Metabolic alkalosis
3.感染控制与患者安全

答案: C · 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

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

答案: A · Yes, near misses are reported so system weaknesses can be fixed

为什么是这个答案

Near misses show where errors can slip through and are reported in the same way as errors that reach the patient. Learning from them prevents future harm.

答案

A · Yes, near misses are reported so system weaknesses can be fixed
5.实验室检查值与电解质

答案: C · The results meet the criteria for diabetes

为什么是这个答案

Two fasting results of 126 mg/dL (7.0 mmol/L) or more confirm diabetes in a person without symptoms. Prediabetes is 100–125 mg/dL. The nurse helps the patient understand the next steps, including education and follow-up.核对依据: Diabetes · MedlinePlus (NIH) (2025)

答案

C · The results meet the criteria for diabetes
6.实验室检查值与电解质

答案: C · 静脉输注 0.9% 氯化钠

为什么是这个答案

高钙血症导致大量排尿和脱水。静脉生理盐水可恢复血容量并帮助肾脏排钙；随后通常使用双膦酸盐。噻嗪类药物减少钙的排泄，而制动会使骨释放钙。核对依据: Hypercalcemia · MedlinePlus (NIH) (2026)

答案

C · 静脉输注 0.9% 氯化钠
7.临床护理

答案: A · A person must be assumed to have capacity unless it is shown that they lack it

为什么是这个答案

The Act begins by presuming capacity. Capacity is decision-specific and time-specific, and people must be given all practicable help to make their own decision.

答案

A · A person must be assumed to have capacity unless it is shown that they lack it
8.临床护理

答案: B · Bleeding from ruptured oesophageal varices

为什么是这个答案

Portal hypertension in cirrhosis causes oesophageal varices, which can bleed massively. This needs resuscitation, urgent endoscopy and specific drug treatment.

答案

B · Bleeding from ruptured oesophageal varices
9.内外科护理：心血管与呼吸

答案: A · The reading will be falsely high

为什么是这个答案

A cuff that is too small needs a higher pressure to compress the brachial artery, giving a falsely high reading. A cuff that is too large can give a falsely low reading. The bladder should encircle most of the arm, so cuff size is chosen by arm circumference.

答案

A · The reading will be falsely high
10.内外科护理：心血管与呼吸

答案: A · Check vital signs, report urgently and anticipate a blood count

为什么是这个答案

Melaena with postural dizziness suggests upper gastrointestinal bleeding, a risk with dual antiplatelet therapy. The nurse assesses for shock, informs the team urgently and expects bloods, a group and save (type and screen) and possibly endoscopy. Stopping antiplatelets after a stent risks stent thrombosis, so the decision belongs to the medical and cardiology team.

答案

A · Check vital signs, report urgently and anticipate a blood count
11.内外科护理：神经、内分泌与肾脏

答案: A · Preventive antibiotics

为什么是这个答案

Close contacts, such as people living in the same household, are offered chemoprophylaxis, for example with ciprofloxacin or rifampicin (rifampin), to clear carriage. Public health teams usually coordinate this.

答案

A · Preventive antibiotics
12.内外科护理：神经、内分泌与肾脏

答案: D · Low blood volume can worsen vasospasm and brain ischaemia

为什么是这个答案

Hyponatraemia after subarachnoid haemorrhage may come from SIADH or cerebral salt wasting. Restricting fluid can cause hypovolaemia, which makes delayed cerebral ischaemia more likely. Sodium is usually corrected with fluids or salt under specialist advice.

答案

D · Low blood volume can worsen vasospasm and brain ischaemia
13.内外科护理：消化、围手术期与肿瘤

答案: A · To stop the inner bumper becoming buried in the stomach wall

为什么是这个答案

Buried bumper syndrome occurs when the internal fixator embeds in the gastric wall. Following local guidance, the tube is gently advanced, rotated and returned once healed, and the external fixator is kept slightly loose.

答案

A · To stop the inner bumper becoming buried in the stomach wall
14.内外科护理：消化、围手术期与肿瘤

答案: B · Stop the feed and assess the airway and breathing

为什么是这个答案

Coughing and desaturation suggest aspiration or a displaced tube. The feed is stopped, the patient is sat up, oxygen is given as needed, and medical review and checking of tube position follow.

答案

B · Stop the feed and assess the airway and breathing

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