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

在综合内科病房，护士应首先看哪位患者？

  1. A一名轻度紧张性头痛的患者，要求服用对乙酰氨基酚
  2. B一名抑郁症患者，已将自己的物品送人并有自杀计划
  3. C一名患者要求提供关于明天出院的书面资料
  4. D一名高血压患者，血压 136/84 mmHg
2.优先排序与委派困难

The charge nurse overhears four instructions from an RN to a nursing assistant. Which one needs to be corrected?

  1. A“Check his glucose and give the insulin according to the sliding scale.”
  2. B“Help him wash and change, and tell me at once if you see any red or broken skin.”
  3. C“Check his glucose before lunch and tell me the number straight away.”
  4. D“Walk him to the bathroom and back, and stay with him the whole time.”
3.感染控制与患者安全中等

Why is keeping a patient warm (normothermia) during surgery part of infection prevention?

  1. AWarmth sterilizes the surgical site
  2. BWarm patients do not need antibiotic prophylaxis
  3. CCold makes bacteria grow faster in the operating room air and on the drapes
  4. DLow body temperature reduces blood flow and immune function in the wound
4.感染控制与患者安全困难

An IV bag from the pharmacy holds the correct drug, but the label shows another patient’s name. What should the nurse do?

  1. AAsk the patient whether it is fine to use the bag
  2. BCross out the name and write in the correct patient’s name
  3. CNot hang it, and get a correctly labeled bag from the pharmacy
  4. DHang it, because the drug and dose are correct
5.实验室检查值与电解质中等

A patient has taken hydrochlorothiazide for several years. Which laboratory change is a recognized effect of this drug?

  1. AA rise in serum potassium
  2. BA fall in serum calcium
  3. CA rise in serum uric acid
  4. DA fall in blood glucose
6.实验室检查值与电解质困难

The nurse teaches a patient with severe neutropenia after chemotherapy. Which statement shows a need for further teaching?

  1. A"I'll check my temperature rectally to be accurate"
  2. B"I'll call the clinic if my temperature rises"
  3. C"I'll avoid people who have a cold or the flu"
  4. D"I'll wash my hands before eating and after the toilet"
7.临床护理中等

Why is it important to prevent hypothermia during and after surgery?

  1. AIt causes high blood glucose only
  2. BIt makes the patient's pain disappear
  3. CIt increases the risk of wound infection, bleeding and cardiac complications
  4. DIt makes the patient wake up too quickly and become agitated in recovery
8.临床护理困难

A nurse teaches a patient with hypertension about their medicines. Which statement shows a need for further teaching?

  1. A"I'll keep taking my tablets even if I feel well."
  2. B"I'll stop my tablets once my readings are normal."
  3. C"I'll get up slowly from sitting."
  4. D"I'll have my blood pressure checked regularly."
9.内外科护理：心血管与呼吸中等

Why are IV fluids given cautiously to a patient with heart failure?

  1. AIV fluids stop diuretics from being absorbed
  2. BIV fluids lower the blood pressure dangerously
  3. CIV fluids directly damage the heart valves
  4. DExtra volume can quickly cause pulmonary oedema
10.内外科护理：心血管与呼吸困难

一名因心房颤动服用华法林的患者被开具克拉霉素。哪项措施最恰当？

  1. A整个抗生素疗程期间停用华法林
  2. B询问是否应提前检查 INR，因为它可能升高
  3. C不作任何改变，因为抗生素不影响华法林
  4. D疗程期间将华法林剂量加倍
11.内外科护理：神经、内分泌与肾脏中等

A patient has just started levetiracetam. Which side effect should the nurse teach them to report?

  1. ASwelling and overgrowth of the gums around the teeth
  2. BA persistent dry cough at night
  3. COrange discoloration of the urine
  4. DChanges in mood, such as irritability, low mood or anger
12.内外科护理：神经、内分泌与肾脏困难

A nurse teaches foot care to a patient with diabetic neuropathy. Which statement shows a need for further teaching?

  1. A"I will check my feet every day, using a mirror for the soles."
  2. B"I will check that the bath water is not too hot using my elbow."
  3. C"I will buy corn plasters from the pharmacy for my corn."
  4. D"I will wear socks and shoes that fit well and do not rub."
13.内外科护理：消化、围手术期与肿瘤中等

Why is the "whoosh" test no longer used to check nasogastric tube position?

  1. AAir can be heard even when the tube is in the lung
  2. BThe test is far too painful for most patients to tolerate
  3. CIt needs an X-ray machine at the bedside
  4. DThe air always makes the tube block
14.内外科护理：消化、围手术期与肿瘤困难

In week 5 of radiotherapy, the skin in the treatment field is broken, moist and painful. What should the nurse do?

  1. AReport it, keep it clean and use a non-adherent dressing
  2. BUse a heat pad to speed healing
  3. CScrub the area with soap to prevent infection
  4. DApply adhesive tape directly over the area to protect it from clothing

3溶液

1.优先排序与委派

答案: B · 一名抑郁症患者，已将自己的物品送人并有自杀计划

为什么是这个答案

送人物品和有计划是自杀的警示信号，属于即时的安全威胁。其他患者病情稳定，他们的需要可以等待。

答案

B · 一名抑郁症患者，已将自己的物品送人并有自杀计划
2.优先排序与委派

答案: A · “Check his glucose and give the insulin according to the sliding scale.”

为什么是这个答案

Giving insulin is medication administration and needs a licensed nurse. Measuring glucose, hygiene and supervised walking are suitable tasks with clear reporting instructions.

答案

A · “Check his glucose and give the insulin according to the sliding scale.”
3.感染控制与患者安全

答案: D · Low body temperature reduces blood flow and immune function in the wound

为什么是这个答案

Hypothermia causes vasoconstriction and less oxygen in the wound, which weakens the immune defense. Keeping the patient warm is linked to fewer surgical site infections.

答案

D · Low body temperature reduces blood flow and immune function in the wound
4.感染控制与患者安全

答案: C · Not hang it, and get a correctly labeled bag from the pharmacy

为什么是这个答案

A label with another patient’s name means the bag may be meant for someone else or may differ in other ways. The nurse does not use it, returns it and reports the issue so the error can be investigated.

答案

C · Not hang it, and get a correctly labeled bag from the pharmacy
5.实验室检查值与电解质

答案: C · A rise in serum uric acid

为什么是这个答案

Thiazides reduce uric acid excretion and can trigger gout. They also tend to lower potassium, sodium and magnesium, raise calcium (by reducing its excretion) and raise blood glucose and lipids.核对依据: Hydrochlorothiazide · StatPearls (NCBI Bookshelf) (2026)

答案

C · A rise in serum uric acid
6.实验室检查值与电解质

答案: A · "I'll check my temperature rectally to be accurate"

为什么是这个答案

Rectal temperatures, suppositories and enemas are avoided in neutropenia, because injury to the rectal mucosa can let bacteria into the blood. Prompt reporting of fever, hand hygiene and avoiding sick contacts are correct.

答案

A · "I'll check my temperature rectally to be accurate"
7.临床护理

答案: C · It increases the risk of wound infection, bleeding and cardiac complications

为什么是这个答案

Inadvertent perioperative hypothermia impairs clotting and immune function and increases cardiac events and wound infection. Patients are warmed actively and their temperature monitored.

答案

C · It increases the risk of wound infection, bleeding and cardiac complications
8.临床护理

答案: B · "I'll stop my tablets once my readings are normal."

为什么是这个答案

Hypertension usually needs long-term treatment; stopping because readings are normal often makes blood pressure rise again. Patients should discuss any changes with their prescriber.

答案

B · "I'll stop my tablets once my readings are normal."
9.内外科护理：心血管与呼吸

答案: D · Extra volume can quickly cause pulmonary oedema

为什么是这个答案

In heart failure, the ventricle cannot cope with large increases in preload, so IV fluids can raise filling pressures and cause pulmonary oedema. When fluids are needed, smaller volumes are given with close reassessment of breathing, crackles, JVP, weight and fluid balance.

答案

D · Extra volume can quickly cause pulmonary oedema
10.内外科护理：心血管与呼吸

答案: B · 询问是否应提前检查 INR，因为它可能升高

为什么是这个答案

包括克拉霉素等大环内酯类、某些氟喹诺酮类和复方磺胺甲噁唑在内的几种抗生素，可使 INR 升高并增加出血风险。需要更密切地监测 INR，并可能需要调整剂量。未经建议停用或加倍华法林是不安全的。

答案

B · 询问是否应提前检查 INR，因为它可能升高
11.内外科护理：神经、内分泌与肾脏

答案: D · Changes in mood, such as irritability, low mood or anger

为什么是这个答案

Levetiracetam is widely used and has few drug interactions, but it can cause mood changes, irritability, depression and, rarely, suicidal thoughts. Patients and families should report these. Gum overgrowth is linked to phenytoin.

答案

D · Changes in mood, such as irritability, low mood or anger
12.内外科护理：神经、内分泌与肾脏

答案: C · "I will buy corn plasters from the pharmacy for my corn."

为什么是这个答案

Medicated corn plasters contain acids that can burn the skin and cause ulcers in people with neuropathy or poor circulation. Corns and calluses should be treated by a podiatrist.

答案

C · "I will buy corn plasters from the pharmacy for my corn."
13.内外科护理：消化、围手术期与肿瘤

答案: A · Air can be heard even when the tube is in the lung

为什么是这个答案

Auscultation of injected air cannot distinguish the stomach from the lungs or oesophagus, and misplaced tubes have caused deaths. pH testing of aspirate or X-ray is used instead.

答案

A · Air can be heard even when the tube is in the lung
14.内外科护理：消化、围手术期与肿瘤

答案: A · Report it, keep it clean and use a non-adherent dressing

为什么是这个答案

Moist desquamation is a more severe radiation skin reaction. The radiotherapy team is informed; the area is kept clean and covered with non-adherent dressings, avoiding adhesive on the skin, and analgesia is given. Infection is watched for.

答案

A · Report it, keep it clean and use a non-adherent dressing

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