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’s chest tube becomes disconnected from the drainage system. What should the nurse do first?

  1. ARemove the tube and cover the site
  2. BPlace the end of the tube in a bottle of sterile water
  3. CWait for the provider to arrive before doing anything else
  4. DClamp the tube for the rest of the shift
2.优先排序与委派困难

在心脏科病房，护士应首先看哪位患者？

  1. A一名心力衰竭患者，自昨天起体重增加了 0.3 kg
  2. B一名被要求明天扫描前禁食的患者
  3. C一名服用地高辛的患者，脉搏 48 次/分，恶心，钾 3.0 mEq/L
  4. D一名房颤患者，心率 88 次/分，不规则，一如既往
3.感染控制与患者安全中等

A patient is on seizure precautions. Which equipment should be ready at the bedside?

  1. AAn ice pack to place on the forehead
  2. BRestraints ready for all four limbs
  3. CA tongue blade to put between the teeth
  4. DWorking suction and oxygen equipment
4.感染控制与患者安全困难

A toddler has bruises of different ages and a burn, and the parent’s explanation does not fit the injuries. What should the nurse do?

  1. AConfront the parent and ask them to admit to abuse
  2. BDocument only and say nothing to anyone
  3. CWait until there is clear proof of abuse before reporting anything at all
  4. DReport the concern following child-protection (safeguarding) procedures
5.实验室检查值与电解质中等

为什么肝衰竭患者即使没有服用华法林，INR 也可能升高？

  1. A肝脏合成大多数凝血因子，因此合成减少
  2. B胆红素直接破坏凝血因子
  3. C白蛋白是一种凝血因子，其水平下降
  4. D肾脏不再从血液中清除凝血因子
6.实验室检查值与电解质困难

Which patient's result should the nurse act on first?

  1. AHemoglobin 6.4 g/dL (64 g/L) with new chest pain and a pulse of 124/min
  2. BHemoglobin 9.6 g/dL (96 g/L) in a patient with stable chronic kidney disease
  3. CPlatelets 140 × 10³/µL in a patient with mild chronic liver disease
  4. DFerritin 15 ng/mL in a well patient with known iron-deficiency anemia on oral iron
7.临床护理中等

Why are alternate sutures sometimes removed first when taking out stitches?

  1. ATo reduce the cost of dressings
  2. BTo make the procedure faster
  3. CBecause the remaining sutures dissolve on their own within a day
  4. DTo check the wound stays closed before removing the rest
8.临床护理困难

肠切除术后两天，一名患者疼痛加重、发热、心动过速，伤口引流管中的液体看起来像粪便。最可能发生了什么？

  1. A尿潴留
  2. B吻合口瘘
  3. C正常的术后恢复
  4. D便秘
9.内外科护理：心血管与呼吸中等

Which skin changes around the ankles are typical of chronic venous insufficiency?

  1. AA sharply defined red patch with fever
  2. BA cold, white foot with no pulse
  3. CPale, shiny, hairless skin with weak pulses
  4. DBrown staining, swelling and dry, itchy skin
10.内外科护理：心血管与呼吸困难

肝素输注第 6 天，患者血小板计数下降超过一半，并且一侧手臂新出现肿胀。护士应预期什么？

  1. A停用所有肝素，并开始使用非肝素类抗凝药
  2. B停用所有抗凝治疗两周
  3. C继续使用肝素并输注血小板
  4. D改用低分子量肝素，因为它是另一种药
11.内外科护理：神经、内分泌与肾脏中等

腹膜透析液使用前应如何加温？

  1. A在一盆热的自来水中
  2. B在专用的干热加温器中
  3. C应直接从冰箱取出冷用
  4. D在微波炉中
12.内外科护理：神经、内分泌与肾脏困难

A patient with trigeminal neuralgia has lost weight and has poor oral hygiene. Which plan is most appropriate?

  1. AOffer soft, lukewarm food and advise chewing on the unaffected side
  2. BEncourage hard, crunchy foods to strengthen the jaw muscles
  3. CTell the patient to stop brushing their teeth completely
  4. DAdvise very hot drinks to relax the facial nerves
13.内外科护理：消化、围手术期与肿瘤中等

What are anticipatory ("just in case") medicines at the end of life usually prescribed for?

  1. AInfection prevention and vaccination
  2. BHigh blood pressure, high cholesterol and diabetes
  3. CPain, nausea, agitation and respiratory secretions
  4. DWeight gain and appetite stimulation
14.内外科护理：消化、围手术期与肿瘤困难

A colleague suggests giving a saline injection to see whether a patient's pain is "real". What is the best response?

  1. AIt is acceptable if a senior nurse gives the saline
  2. BIt is a good idea, as long as the patient is not told about it afterwards
  3. CDeceptive placebos are unethical and do not show pain is "fake"
  4. DIt should be done only for patients with chronic pain

3溶液

1.优先排序与委派

答案: B · Place the end of the tube in a bottle of sterile water

为什么是这个答案

Putting the tube end in sterile water creates a temporary water seal until a new drainage system is connected. Long clamping can cause a tension pneumothorax, and the nurse does not remove the tube.

答案

B · Place the end of the tube in a bottle of sterile water
2.优先排序与委派

答案: C · 一名服用地高辛的患者，脉搏 48 次/分，恶心，钾 3.0 mEq/L

为什么是这个答案

服用地高辛的患者出现心动过缓和恶心提示中毒，而低钾使其更可能发生且更危险。体重的小幅变化以及已知且得到控制的房颤是稳定的。

答案

C · 一名服用地高辛的患者，脉搏 48 次/分，恶心，钾 3.0 mEq/L
3.感染控制与患者安全

答案: D · Working suction and oxygen equipment

为什么是这个答案

Suction and oxygen are kept ready to manage secretions and support breathing during or after a seizure. Nothing is put in the mouth, and restraints are not used because they can cause injury.

答案

D · Working suction and oxygen equipment
4.感染控制与患者安全

答案: D · Report the concern following child-protection (safeguarding) procedures

为什么是这个答案

Injuries that do not match the history must be reported, and proof is not needed. In the US, nurses are legally mandated reporters; in the UK and many other countries, safeguarding procedures require the concern to be referred to the designated lead or children’s social care. The child’s safety is ensured and the findings are documented factually.

答案

D · Report the concern following child-protection (safeguarding) procedures
5.实验室检查值与电解质

答案: A · 肝脏合成大多数凝血因子，因此合成减少

为什么是这个答案

肝脏合成大多数凝血因子，包括依赖维生素 K 的因子。在严重肝病中，它们的合成减少，因此 INR 升高。INR 升高是反映肝衰竭严重程度的指标之一。核对依据: Prothrombin Time Test and INR (PT/INR) · MedlinePlus (NIH) (2024)

答案

A · 肝脏合成大多数凝血因子，因此合成减少
6.实验室检查值与电解质

答案: A · Hemoglobin 6.4 g/dL (64 g/L) with new chest pain and a pulse of 124/min

为什么是这个答案

Severe anemia with chest pain and tachycardia suggests the heart is not receiving enough oxygen, which needs urgent action, often including transfusion. The other results are mildly abnormal but expected or stable.核对依据: Anemia · StatPearls (NCBI Bookshelf) (2026)

答案

A · Hemoglobin 6.4 g/dL (64 g/L) with new chest pain and a pulse of 124/min
7.临床护理

答案: D · To check the wound stays closed before removing the rest

为什么是这个答案

Removing alternate sutures allows the nurse to see whether the wound edges stay together. If they begin to separate, the remaining sutures can be left and the team informed.

答案

D · To check the wound stays closed before removing the rest
8.临床护理

答案: B · 吻合口瘘

为什么是这个答案

吻合口瘘使肠内容物进入腹腔，引起腹膜炎和脓毒症。这是需要紧急评估的外科急症。

答案

B · 吻合口瘘
9.内外科护理：心血管与呼吸

答案: D · Brown staining, swelling and dry, itchy skin

为什么是这个答案

High venous pressure causes oedema and leakage of red cells, depositing haemosiderin (brown staining), with venous eczema and lipodermatosclerosis. Pale, shiny, hairless skin suggests arterial disease. Venous ulcers often form above the medial malleolus.

答案

D · Brown staining, swelling and dry, itchy skin
10.内外科护理：心血管与呼吸

答案: A · 停用所有肝素，并开始使用非肝素类抗凝药

为什么是这个答案

肝素诱导的血小板减少症通常在开始使用肝素后 5–10 天出现，表现为血小板大幅下降和新发血栓形成。必须停用所有肝素，包括低分子量肝素和肝素封管液，并使用非肝素类抗凝药（如阿加曲班）。一般应避免输注血小板，停用抗凝治疗会使血栓风险极高。

答案

A · 停用所有肝素，并开始使用非肝素类抗凝药
11.内外科护理：神经、内分泌与肾脏

答案: B · 在专用的干热加温器中

为什么是这个答案

将透析液加温至体温可提高舒适度。微波炉加热不均匀，会产生热点；浸泡可能污染接口。应使用制造商认可的干热加温器。

答案

B · 在专用的干热加温器中
12.内外科护理：神经、内分泌与肾脏

答案: A · Offer soft, lukewarm food and advise chewing on the unaffected side

为什么是这个答案

Patients may avoid eating and brushing their teeth because these trigger attacks. Soft, lukewarm food, chewing on the unaffected side, gentle oral care and effective drug treatment help maintain nutrition and hygiene.

答案

A · Offer soft, lukewarm food and advise chewing on the unaffected side
13.内外科护理：消化、围手术期与肿瘤

答案: C · Pain, nausea, agitation and respiratory secretions

为什么是这个答案

Anticipatory medicines are prescribed in advance, usually for subcutaneous use, so that common end-of-life symptoms can be treated quickly without delay, especially at home.

答案

C · Pain, nausea, agitation and respiratory secretions
14.内外科护理：消化、围手术期与肿瘤

答案: C · Deceptive placebos are unethical and do not show pain is "fake"

为什么是这个答案

A placebo response does not mean pain is not real, and giving placebos without consent is deceptive and damages trust. Pain is assessed with the patient and treated according to the plan.

答案

C · Deceptive placebos are unethical and do not show pain is "fake"

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