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

Which practice makes a shift handover safest?

  1. AA quick chat in the corridor with no notes taken
  2. BA structured format, such as SBAR, with time for questions
  3. CHanding over only the patients who had problems during the shift
  4. DLeaving a sticky note on the computer screen for the next nurse
2.优先排序与委派困难

On a cardiac step-down unit, which patient should the nurse assess first?

  1. AHeart failure, weight up 0.5 kg since yesterday, no breathlessness at rest
  2. BDay 2 after a pacemaker insertion, asking when the wound dressing will be changed
  3. CSix hours after a coronary stent, new chest pain with ST elevation on the monitor
  4. DAtrial fibrillation on warfarin with an INR of 2.6 this morning
3.感染控制与患者安全中等

A patient has fallen, and the nurse completes an incident report. Which statement about this report is correct?

  1. AIt is written factually and does not replace documenting the fall in the patient’s record
  2. BIt replaces the need to document the fall in the patient’s record
  3. CIt is only needed when the patient is injured
  4. DA copy of it is placed in the patient’s chart so all staff know about the fall
4.感染控制与患者安全困难

Who should mark the operative site before surgery?

  1. AAny member of the operating room team after anesthesia starts
  2. BThe patient, alone, using a marker pen at home on the night before surgery
  3. CThe person who will perform the procedure, with the patient involved where possible
  4. DThe admitting clerk, using the information written on the consent form
5.实验室检查值与电解质中等

A patient with joint aches has a positive antinuclear antibody (ANA) test. Which statement is correct?

  1. AA positive ANA rules out all other autoimmune diseases
  2. BA positive ANA means the patient has a viral infection
  3. CA positive ANA proves the patient has rheumatoid arthritis
  4. DA positive ANA supports lupus but does not diagnose it alone
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静脉输注 0.9% 氯化钠
  2. B严格卧床休息
  3. C口服钙补充剂
  4. D噻嗪类利尿剂
7.临床护理中等

Why is oxygen often humidified for a patient with a tracheostomy?

  1. ADry oxygen causes high blood glucose
  2. BHumidification lowers the oxygen concentration to a safer level
  3. CHumidity is needed for the oxygen to work as a drug
  4. DThe tube bypasses the nose, which normally warms and moistens air
8.临床护理困难

Which route and site are recommended for the first dose of adrenaline (epinephrine) in anaphylaxis on a ward?

  1. AIntramuscular injection into the anterolateral thigh
  2. BIntravenous bolus given by the nurse without monitoring
  3. CSubcutaneous injection into the upper arm
  4. DOral tablet dissolved under the tongue
9.内外科护理：心血管与呼吸中等

A patient's blood pressure is high in clinic but normal on home readings. Which step best confirms the diagnosis?

  1. AA single repeat reading in the same clinic visit
  2. BA chest X-ray
  3. CStarting two antihypertensive drugs at once at full dose
  4. DAmbulatory or structured home blood pressure monitoring
10.内外科护理：心血管与呼吸困难

一名使用 28% 文丘里面罩（SpO₂ 90%）的 COPD 患者想吃饭。最恰当的方案是什么？

  1. A进餐期间完全撤掉氧气，之后再恢复
  2. B进餐期间改用 15 L/min 的非重复呼吸面罩
  3. C继续戴文丘里面罩，只通过吸管喝流质
  4. D改用低流量鼻导管，使 SpO₂ 保持在 88–92%
11.内外科护理：神经、内分泌与肾脏中等

Why is once-daily prednisolone usually taken in the morning with food?

  1. ABecause food doubles the strength of the dose
  2. BTo match the natural cortisol rhythm and protect the stomach
  3. CBecause it cannot be absorbed at night
  4. DBecause it causes drowsiness and is safer to take during the day
12.内外科护理：神经、内分泌与肾脏困难

一名持续夜间肠内营养的患者，其胰岛素的给药时间与营养液相匹配。凌晨 02:00 导管堵塞，营养液停止。主要风险是什么，护士应怎么做？

  1. A没有风险；胰岛素只是会被储存到重新喂养时
  2. B低血糖；经常检测血糖，并按计划进行血糖保护
  3. C高血糖；立即额外给一剂胰岛素
  4. D酮症酸中毒；停用所有胰岛素直到早晨
13.内外科护理：消化、围手术期与肿瘤中等

造口袋底盘的开口应剪多大？

  1. A比造口四周大约 2–3 mm
  2. B任何大小，只要盖住造口即可
  3. C略小于造口以便紧密密封
  4. D比造口四周大约 2 cm
14.内外科护理：消化、围手术期与肿瘤困难

大面积烧伤后第 3 天，患者开始排出大量尿液。护士应预期哪种电解质问题？

  1. A高钠血症，因为肾脏开始潴留钠
  2. B高钾血症，因为新的组织损伤释放钾
  3. C卧床和制动引起的高钙血症
  4. D低钾血症，因为液体回到循环中

3溶液

1.优先排序与委派

答案: B · A structured format, such as SBAR, with time for questions

为什么是这个答案

Handover is a high-risk moment for errors. A structured format and the chance to ask questions help the next nurse understand each patient’s condition and priorities.

答案

B · A structured format, such as SBAR, with time for questions
2.优先排序与委派

答案: C · Six hours after a coronary stent, new chest pain with ST elevation on the monitor

为什么是这个答案

New chest pain with ST elevation after a stent suggests the stent may have blocked, causing an acute myocardial infarction. This is an emergency; the other findings are within target or routine.

答案

C · Six hours after a coronary stent, new chest pain with ST elevation on the monitor
3.感染控制与患者安全

答案: A · It is written factually and does not replace documenting the fall in the patient’s record

为什么是这个答案

The nurse documents the facts of the fall, the assessment and the care given in the patient’s record. The incident report is a separate quality-improvement document and is not filed in the chart. Policies differ on whether the record notes that a report was made: many US facilities advise against it, while many UK services record the report reference. Falls are reported whether or not there is an injury.

答案

A · It is written factually and does not replace documenting the fall in the patient’s record
4.感染控制与患者安全

答案: C · The person who will perform the procedure, with the patient involved where possible

为什么是这个答案

Under the Universal Protocol, the site is marked by the person performing the procedure, or an authorized delegate, ideally while the patient is awake and can confirm it. This helps prevent wrong-site surgery.

答案

C · The person who will perform the procedure, with the patient involved where possible
5.实验室检查值与电解质

答案: D · A positive ANA supports lupus but does not diagnose it alone

为什么是这个答案

Almost all patients with SLE have a positive ANA, so a negative test makes lupus unlikely. However, many healthy people and patients with other conditions also have a positive ANA, so diagnosis needs the clinical picture and more specific antibodies such as anti-dsDNA.核对依据: ANA (Antinuclear Antibody) Test · MedlinePlus (NIH) (2025)

答案

D · A positive ANA supports lupus but does not diagnose it alone
6.实验室检查值与电解质

答案: A · 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

A · 静脉输注 0.9% 氯化钠
7.临床护理

答案: D · The tube bypasses the nose, which normally warms and moistens air

为什么是这个答案

The upper airway normally humidifies inspired air. Without it, secretions become thick and may block the tracheostomy tube, so humidification is used.

答案

D · The tube bypasses the nose, which normally warms and moistens air
8.临床护理

答案: A · Intramuscular injection into the anterolateral thigh

为什么是这个答案

IM adrenaline into the outer thigh is absorbed quickly and is the first-line route. IV adrenaline is reserved for experienced specialists with full monitoring because of the risk of arrhythmias.

答案

A · Intramuscular injection into the anterolateral thigh
9.内外科护理：心血管与呼吸

答案: D · Ambulatory or structured home blood pressure monitoring

为什么是这个答案

"White-coat" hypertension means raised readings only in clinical settings. Ambulatory monitoring over 24 hours or a structured series of home readings gives a truer picture and is widely recommended before diagnosing hypertension.

答案

D · Ambulatory or structured home blood pressure monitoring
10.内外科护理：心血管与呼吸

答案: D · 改用低流量鼻导管，使 SpO₂ 保持在 88–92%

为什么是这个答案

氧疗是按目标范围开具的，需要吸氧的患者不应因进餐而停氧。鼻导管便于进食和说话；流量（例如 1–2 L/min）经滴定使饱和度保持在目标范围内。高浓度氧气有高碳酸血症的风险。

答案

D · 改用低流量鼻导管，使 SpO₂ 保持在 88–92%
11.内外科护理：神经、内分泌与肾脏

答案: B · To match the natural cortisol rhythm and protect the stomach

为什么是这个答案

Morning dosing mimics the normal early-morning cortisol peak, causes less adrenal suppression and less sleep disturbance. Taking it with food reduces gastric irritation.

答案

B · To match the natural cortisol rhythm and protect the stomach
12.内外科护理：神经、内分泌与肾脏

答案: B · 低血糖；经常检测血糖，并按计划进行血糖保护

为什么是这个答案

如果为覆盖营养液而给予的胰岛素仍在起作用时营养液停止，患者可能发生低血糖。护士应经常检测血糖，通知团队，尽可能恢复喂养，并按处方计划（如静脉葡萄糖）执行，直到重新开始喂养。1 型糖尿病的基础胰岛素不能简单停用。

答案

B · 低血糖；经常检测血糖，并按计划进行血糖保护
13.内外科护理：消化、围手术期与肿瘤

答案: A · 比造口四周大约 2–3 mm

为什么是这个答案

开口应剪得紧贴造口周围，留出约 2–3 mm（约 1/8 英寸）的小间隙。太大会使皮肤暴露于排出物；太小可能割伤造口。造口在最初几周内会缩小，所以要重复测量。

答案

A · 比造口四周大约 2–3 mm
14.内外科护理：消化、围手术期与肿瘤

答案: D · 低钾血症，因为液体回到循环中

为什么是这个答案

在最初几小时，细胞破坏和液体转移可使钾升高。约 48–72 小时后，毛细血管完整性改善，液体回到循环，开始利尿，伴钾丢失和低钾血症。全程应监测电解质。

答案

D · 低钾血症，因为液体回到循环中

本内容为独立练习材料。ExamProblems 与该考试的主办机构没有隶属关系，也未获其认可，考试名称仅用于描述内容。 NCLEX®, NCLEX-RN® and NCLEX-PN® 是 the National Council of State Boards of Nursing, Inc. (NCSBN) 的商标，该机构与 ExamProblems 无关，不为其背书，也不保证其准确性。

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