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

哪项陈述表明对委派中的问责有正确理解？

  1. A“一旦我委派了任务，就与我无关了。”
  2. B“护理助理要对该任务是否适合委派负责。”
  3. C“如果任务出了问题，只有助理负责。”
  4. D“我对决定委派以及跟进结果负有问责。”
2.优先排序与委派困难

A patient is deteriorating quickly. The nurse has called the provider twice, but the provider has not come. What is the best action?

  1. AWait another hour and call the provider again
  2. BActivate the rapid response team
  3. CAsk the patient’s family to call the provider
  4. DDocument the concern and continue routine care
3.感染控制与患者安全中等

Which technique is correct when collecting a wound culture?

  1. ACollect the sample only after antibiotics have been started
  2. BSwab the old pus on the dressing that was just removed from the wound
  3. CUse one swab to sample two different wounds
  4. DClean the wound with sterile saline first, then swab clean tissue
4.感染控制与患者安全困难

Minutes after the first IV dose of an antibiotic starts, the patient develops wheezing, hives and low blood pressure. What should the nurse do first?

  1. AGive an oral antihistamine
  2. BSlow the infusion rate
  3. CRecord the new allergy in the chart
  4. DStop the infusion
5.实验室检查值与电解质中等

A patient with hyperkalemia is prescribed an oral potassium binder such as patiromer or sodium zirconium cyclosilicate. How does this drug lower potassium?

  1. AIt stops the kidneys from absorbing water in the tubules
  2. BIt binds potassium in the gut so it leaves in the stool
  3. CIt moves potassium into cells in the next few minutes
  4. DIt protects the heart muscle against high potassium levels
6.实验室检查值与电解质困难

Four drug levels are reported. Which patient should the nurse assess first?

  1. ALithium 1.8 mEq/L with a new coarse tremor
  2. BValproate 75 mcg/mL with no symptoms
  3. CDigoxin 1.0 ng/mL with a pulse of 72/min
  4. DPhenytoin 15 mcg/mL with no symptoms
7.临床护理中等

Which type of painkiller should a patient with liver cirrhosis usually avoid?

  1. AParacetamol (acetaminophen), given in a carefully reduced and monitored dose
  2. BNon-steroidal anti-inflammatory drugs such as ibuprofen
  3. CHot packs applied to a painful joint
  4. DLocal anaesthetic creams
8.临床护理困难

A patient with a confirmed pulmonary embolism is started on anticoagulation. Which statement best explains its purpose?

  1. AIt is mainly given to lower the blood pressure
  2. BIt stops the clot growing and prevents new clots while the body breaks it down
  3. CIt dissolves the clot completely within minutes of the first dose being given
  4. DIt thins the blood so that the lungs absorb more oxygen
9.内外科护理：心血管与呼吸中等

How does intermittent pneumatic compression help prevent DVT?

  1. AIt squeezes the legs in cycles to push venous blood towards the heart
  2. BIt breaks up and dissolves clots that have already formed in the veins
  3. CIt keeps the legs completely still to protect the veins
  4. DIt warms the legs gently so the blood becomes thinner and flows faster
10.内外科护理：心血管与呼吸困难

After six weeks of treatment for tuberculosis, a patient has nausea, dark urine and yellow eyes. What should the nurse do?

  1. AReassure the patient that the urine colour is due to rifampicin
  2. BAdvise taking the tablets with an alcoholic drink to settle the stomach
  3. CWithhold the next doses and report urgently for liver tests
  4. DDouble the isoniazid dose to clear the infection faster
11.内外科护理：神经、内分泌与肾脏中等

During continuous bladder irrigation, 3200 mL drains out in a shift. 2500 mL of irrigation fluid was put in. What is the true urine output?

  1. A700 mL
  2. B3200 mL
  3. C2500 mL
  4. D5700 mL
12.内外科护理：神经、内分泌与肾脏困难

A patient's corrected calcium is 1.7 mmol/L (about 6.8 mg/dL). Which ECG change is most typical?

  1. AST elevation in all leads
  2. BA shortened QT interval
  3. CA prolonged QT interval
  4. DTall, peaked T waves
13.内外科护理：消化、围手术期与肿瘤中等

Why does a patient need lifelong vitamin B12 injections after total gastrectomy?

  1. AVitamin B12 is lost in the urine after the surgery
  2. BThe liver can no longer store any vitamins
  3. CIntrinsic factor from the stomach is no longer made
  4. DThe small bowel stops absorbing all nutrients
14.内外科护理：消化、围手术期与肿瘤困难

A patient arrives in the anaesthetic room without an identity band. What should the nurse do?

  1. AStop and confirm identity, then apply a band
  2. BProceed because the patient can say their name
  3. CProceed and add a band once in recovery
  4. DUse the spare identity band from the front of the patient's notes folder

3溶液

1.优先排序与委派

答案: D · “我对决定委派以及跟进结果负有问责。”

为什么是这个答案

委派的护士对委派这一决定以及监督和评价负有问责。被委派者负责在其能力范围内正确地执行任务。

答案

D · “我对决定委派以及跟进结果负有问责。”
2.优先排序与委派

答案: B · Activate the rapid response team

为什么是这个答案

Nurses can call the rapid response team directly when a patient is deteriorating. The nurse also informs the charge nurse and follows the chain of command about the provider’s lack of response.

答案

B · Activate the rapid response team
3.感染控制与患者安全

答案: D · Clean the wound with sterile saline first, then swab clean tissue

为什么是这个答案

Old exudate contains surface bacteria that may not be causing the infection. The wound is cleaned with sterile saline and then swabbed over clean, viable tissue, ideally before antibiotics start.

答案

D · Clean the wound with sterile saline first, then swab clean tissue
4.感染控制与患者安全

答案: D · Stop the infusion

为什么是这个答案

These are signs of anaphylaxis. The nurse stops the infusion at once, calls for help and supports the airway, and intramuscular epinephrine (adrenaline) is the first-line treatment. Documentation comes later.

答案

D · Stop the infusion
5.实验室检查值与电解质

答案: B · It binds potassium in the gut so it leaves in the stool

为什么是这个答案

Potassium binders exchange potassium in the gut for another ion, so potassium is removed from the body in the stool. They act over hours, so they are not used alone for emergencies; calcium protects the heart, and insulin with glucose shifts potassium into cells quickly.核对依据: High potassium level · MedlinePlus (NIH) (2025)

答案

B · It binds potassium in the gut so it leaves in the stool
6.实验室检查值与电解质

答案: A · Lithium 1.8 mEq/L with a new coarse tremor

为什么是这个答案

A lithium level of 1.8 mEq/L with a coarse tremor suggests toxicity, which can progress to confusion and seizures. The digoxin, phenytoin and valproate levels are within commonly cited ranges and the patients are stable.

答案

A · Lithium 1.8 mEq/L with a new coarse tremor
7.临床护理

答案: B · Non-steroidal anti-inflammatory drugs such as ibuprofen

为什么是这个答案

NSAIDs increase the risk of GI bleeding and can trigger kidney failure and fluid retention in cirrhosis. Paracetamol is usually preferred at a lower, carefully chosen dose.

答案

B · Non-steroidal anti-inflammatory drugs such as ibuprofen
8.临床护理

答案: B · It stops the clot growing and prevents new clots while the body breaks it down

为什么是这个答案

Anticoagulants prevent clot extension and new clots; the body's own fibrinolysis gradually breaks down the existing clot. Thrombolysis, which actively dissolves clots, is reserved for massive PE with shock.

答案

B · It stops the clot growing and prevents new clots while the body breaks it down
9.内外科护理：心血管与呼吸

答案: A · It squeezes the legs in cycles to push venous blood towards the heart

为什么是这个答案

Inflatable sleeves around the calves or feet inflate and deflate in cycles, increasing venous return and reducing stasis. They are used when anticoagulation is unsuitable or alongside it. They are not used on a leg with a known DVT or severe arterial disease.

答案

A · It squeezes the legs in cycles to push venous blood towards the heart
10.内外科护理：心血管与呼吸

答案: C · Withhold the next doses and report urgently for liver tests

为什么是这个答案

Isoniazid, rifampicin and pyrazinamide can all cause hepatotoxicity. Jaundice, dark urine and nausea suggest drug-induced hepatitis, so the drugs are stopped and liver function is checked urgently. Orange urine from rifampicin does not cause yellow eyes. Alcohol increases the risk.

答案

C · Withhold the next doses and report urgently for liver tests
11.内外科护理：神经、内分泌与肾脏

答案: A · 700 mL

为什么是这个答案

True urine output equals total drainage minus irrigation volume: 3200 − 2500 = 700 mL. If drainage is less than the irrigant volume, the catheter may be blocked and fluid is being retained.

答案

A · 700 mL
12.内外科护理：神经、内分泌与肾脏

答案: C · A prolonged QT interval

为什么是这个答案

Hypocalcaemia prolongs the QT interval, which can lead to dangerous arrhythmias. A short QT is seen in hypercalcaemia, and peaked T waves are typical of hyperkalaemia.

答案

C · A prolonged QT interval
13.内外科护理：消化、围手术期与肿瘤

答案: C · Intrinsic factor from the stomach is no longer made

为什么是这个答案

Parietal cells of the stomach make intrinsic factor, which is needed for B12 absorption in the terminal ileum. Without it, pernicious-type anaemia and neuropathy develop unless B12 is given by injection.

答案

C · Intrinsic factor from the stomach is no longer made
14.内外科护理：消化、围手术期与肿瘤

答案: A · Stop and confirm identity, then apply a band

为什么是这个答案

Correct identification before anaesthesia prevents wrong-patient surgery. The process stops until identity is confirmed with the patient and records and a band is applied, following the checklist.

答案

A · Stop and confirm identity, then apply a band

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