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

一名患者突然流鼻血，意识清醒，呼吸正常。护士首先做什么？

  1. A让患者坐起，身体前倾，并捏住鼻子的软骨部分
  2. B头向后仰，并在颈后敷冰
  3. C让患者用力擤鼻子以清除血块
  4. D让患者平躺，膝下垫枕头
2.优先排序与委派困难

一个团队包括一名 RN、一名 LPN/LVN 和一名护理助理。哪种分工最恰当？

  1. A助理：口服药物；LPN/LVN：护理计划；RN：稳定患者的卫生护理
  2. BRN：新入院患者；LPN/LVN：稳定患者的用药；助理：卫生护理
  3. C助理：新入院患者；LPN/LVN：卫生护理；RN：稳定患者的常规生命体征
  4. DLPN/LVN：所有初步评估；RN：定时用药；助理：出院教育
3.感染控制与患者安全中等

A family member will visit a patient on contact precautions. What should the nurse do?

  1. AShow them how to use the gown and gloves and how to clean their hands
  2. BTell them visits are not allowed at all
  3. CAsk them to wear an N95 respirator only, with no gown or gloves
  4. DTell them precautions only apply to staff
4.感染控制与患者安全困难

A nurse who is not immune to chickenpox was exposed to a patient with varicella before precautions began. What usually happens?

  1. AThe nurse continues working with all patients as usual, including newborns
  2. BThe nurse is assessed and kept from patient contact during the incubation period per policy
  3. CThe nurse must take a two-week course of antibiotics to prevent the infection
  4. DThe nurse only needs to wear gloves for the next month
5.实验室检查值与电解质中等

An older adult with chronic kidney disease takes glyburide (glibenclamide, a sulfonylurea) and has repeated low glucose readings. Why is this a concern?

  1. AThe drug and its metabolites build up and cause long lows
  2. BThe drug makes the glucose meter read falsely low
  3. CThe drug stops working entirely when the kidneys fail
  4. DThe drug causes high potassium that lowers the glucose
6.实验室检查值与电解质困难

A trauma patient receives many units of blood quickly and then develops muscle twitching and low blood pressure. Which laboratory value is most likely to explain this?

  1. AA high serum magnesium
  2. BA low ionized calcium
  3. CA low serum glucose
  4. DA high serum sodium
7.临床护理中等

How does CPAP help a patient with obstructive sleep apnoea?

  1. AIt delivers bronchodilator drugs deep into the lungs overnight
  2. BIt keeps the upper airway open during sleep with continuous air pressure
  3. CIt strengthens the breathing muscles during the day
  4. DIt removes excess carbon dioxide from the lungs by gentle suction
8.临床护理困难

Which action is most important in protecting a patient with severe neutropenia from infection?

  1. ATaking rectal temperatures regularly
  2. BKeeping fresh flowers and plants in the room to help the patient's mood
  3. CStrict hand hygiene by everyone who has contact with the patient
  4. DGiving routine intramuscular injections
9.内外科护理：心血管与呼吸中等

Why is a higher level of HDL cholesterol considered protective?

  1. AHDL is converted into vitamin D in the walls of the arteries
  2. BHDL carries cholesterol from the tissues back to the liver
  3. CHDL thins the blood in the same way as an anticoagulant
  4. DHDL lowers the blood pressure directly
10.内外科护理：心血管与呼吸困难

Four hours after abdominal surgery, a patient's heart rate has risen from 84 to 122/min and they are restless and pale. BP is still 118/76 mmHg, and the surgical drain is filling with blood. What should the nurse conclude?

  1. AThe drain is working well, so no action is needed
  2. BThe tachycardia is from pain and needs only analgesia
  3. CEarly haemorrhagic shock is likely, so escalate urgently
  4. DThe patient is stable because the blood pressure is normal
11.内外科护理：神经、内分泌与肾脏中等

一名卒中患者能听懂别人说的话，但很难找到词语，说话简短而吃力。这是哪种失语？

  1. A面部肌肉无力引起的构音障碍
  2. B完全听不懂的完全性失语
  3. C表达性（Broca）失语
  4. D感受性（Wernicke）失语
12.内外科护理：神经、内分泌与肾脏困难

A patient with lung cancer is confused, dehydrated and constipated, with a corrected calcium of 3.4 mmol/L (about 13.6 mg/dL). What is usually the first treatment?

  1. AA fluid restriction
  2. BIV fluids to rehydrate the patient
  3. COral calcium tablets
  4. DIV calcium gluconate and vitamin D
13.内外科护理：消化、围手术期与肿瘤中等

Why are antibody levels checked after a healthcare worker receives the hepatitis B vaccine?

  1. ATo measure liver damage caused by the vaccine
  2. BTo check whether they caught hepatitis B from the vaccine
  3. CTo decide whether they need a liver biopsy
  4. DTo confirm that the vaccine produced immunity
14.内外科护理：消化、围手术期与肿瘤困难

Four hours after surgery, a catheterised patient's urine output has been 10 mL/h for two hours. Vital signs are stable. What should the nurse check first?

  1. AThat the catheter and tubing are not kinked or blocked
  2. BThe time the patient last ate
  3. CWhether the patient wants a cup of tea
  4. DYesterday's chest X-ray and blood gas results

3溶液

1.优先排序与委派

答案: A · 让患者坐起，身体前倾，并捏住鼻子的软骨部分

为什么是这个答案

身体前倾可使血液不进入气道和胃，用力捏住鼻子的软骨部分通常可止血。头后仰或平躺会使血液流入咽喉。

答案

A · 让患者坐起，身体前倾，并捏住鼻子的软骨部分
2.优先排序与委派

答案: B · RN：新入院患者；LPN/LVN：稳定患者的用药；助理：卫生护理

为什么是这个答案

RN 负责评估和复杂护理，LPN/LVN 护理稳定患者并给予常规药物，助理负责常规的卫生护理和测量。其他选项把任务分配到了超出该人员工作范围的人。

答案

B · RN：新入院患者；LPN/LVN：稳定患者的用药；助理：卫生护理
3.感染控制与患者安全

答案: A · Show them how to use the gown and gloves and how to clean their hands

为什么是这个答案

Visitors are taught how to put on and remove PPE as required by the policy and how to perform hand hygiene, so they protect themselves and other patients.

答案

A · Show them how to use the gown and gloves and how to clean their hands
4.感染控制与患者安全

答案: B · The nurse is assessed and kept from patient contact during the incubation period per policy

为什么是这个答案

A non-immune worker exposed to varicella may become infectious before the rash appears, so they are usually excluded from patient contact for the incubation period, and post-exposure vaccination or other measures may be offered.

答案

B · The nurse is assessed and kept from patient contact during the incubation period per policy
5.实验室检查值与电解质

答案: A · The drug and its metabolites build up and cause long lows

为什么是这个答案

Glyburide and its active metabolites are cleared by the kidneys, so they accumulate in CKD and can cause severe, prolonged hypoglycemia. Older adults are at greater risk. The prescriber is informed, and a different drug is usually chosen.

答案

A · The drug and its metabolites build up and cause long lows
6.实验室检查值与电解质

答案: B · A low ionized calcium

为什么是这个答案

Stored blood contains citrate, which binds calcium. During massive transfusion, citrate can lower ionized calcium, causing tetany, hypotension and arrhythmias. Ionized calcium is monitored and replaced as prescribed.

答案

B · A low ionized calcium
7.临床护理

答案: B · It keeps the upper airway open during sleep with continuous air pressure

为什么是这个答案

Continuous positive airway pressure acts as a splint for the upper airway, preventing collapse and apnoeas. Patients should bring their CPAP machine into hospital.

答案

B · It keeps the upper airway open during sleep with continuous air pressure
8.临床护理

答案: C · Strict hand hygiene by everyone who has contact with the patient

为什么是这个答案

Hand hygiene is the single most effective measure to protect neutropenic patients. Rectal procedures and IM injections are avoided because they can cause mucosal or tissue injury and bleeding.

答案

C · Strict hand hygiene by everyone who has contact with the patient
9.内外科护理：心血管与呼吸

答案: B · HDL carries cholesterol from the tissues back to the liver

为什么是这个答案

HDL transports cholesterol from the tissues and artery walls to the liver for removal (reverse cholesterol transport), so higher levels are linked with lower cardiovascular risk. LDL carries cholesterol to tissues and drives atherosclerosis.

答案

B · HDL carries cholesterol from the tissues back to the liver
10.内外科护理：心血管与呼吸

答案: C · Early haemorrhagic shock is likely, so escalate urgently

为什么是这个答案

Rising heart rate, restlessness, pallor and visible bleeding are signs of compensated haemorrhagic shock. Waiting for hypotension delays treatment. The nurse escalates urgently, gives oxygen, ensures IV access and anticipates bloods, fluids or blood products and surgical review.

答案

C · Early haemorrhagic shock is likely, so escalate urgently
11.内外科护理：神经、内分泌与肾脏

答案: C · 表达性（Broca）失语

为什么是这个答案

表达性失语由额叶 Broca 区受损引起，表现为不流利、费力的言语，理解力相对保留。感受性失语表现为流利但无意义的言语和理解力差。构音障碍是语言功能完整的运动性言语问题。

答案

C · 表达性（Broca）失语
12.内外科护理：神经、内分泌与肾脏

答案: B · IV fluids to rehydrate the patient

为什么是这个答案

Hypercalcaemia causes polyuria and dehydration, which worsen the high calcium. IV fluids are the first step, followed by a bisphosphonate to reduce bone resorption. Calcium is rechecked regularly.

答案

B · IV fluids to rehydrate the patient
13.内外科护理：消化、围手术期与肿瘤

答案: D · To confirm that the vaccine produced immunity

为什么是这个答案

Some people do not develop protective anti-HBs antibodies after vaccination. Testing identifies non-responders, who may need further doses and advice after exposures.

答案

D · To confirm that the vaccine produced immunity
14.内外科护理：消化、围手术期与肿瘤

答案: A · That the catheter and tubing are not kinked or blocked

为什么是这个答案

A sudden low output may be due to a kinked tube or blocked catheter. If drainage is normal, hypovolaemia or kidney injury is considered and the team is informed, with a fluid assessment.

答案

A · That the catheter and tubing are not kinked or blocked

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