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 had a colostomy formed yesterday. Which stoma appearance should be reported straight away?

  1. AA little bleeding when cleaned
  2. BSlightly swollen
  3. CMoist and pink-red
  4. DDark purple or black
2.优先排序与委派困难

A nursing assistant has twice not reported abnormal vital signs to the RN. What is the RN’s best action?

  1. AStop delegating any tasks to the assistant for the rest of the year
  2. BComplain about the assistant to the patients during care
  3. CTalk to the assistant privately, restate what must be reported and follow up closely
  4. DSay nothing to the assistant and quietly recheck all of the assistant’s vital signs in secret
3.感染控制与患者安全中等

在给一片药之前，患者说：“这片药和我平时吃的不一样。”护士应怎么做？

  1. A给半片药并观察有无异常反应
  2. B暂停并重新核对医嘱和药物，然后再给药
  3. C安慰患者并给药
  4. D告诉患者医院里的药片看起来都不一样
4.感染控制与患者安全困难

A patient’s cardiac monitor alarms often because of artifact, and a colleague suggests turning the alarm off. What is the best response?

  1. ATurn the alarm off and check the monitor screen at the nurses’ station every hour instead
  2. BDisconnect the monitor overnight so the patient can sleep
  3. CKeep the alarm on, fix the cause such as electrode placement, and adjust limits only per policy
  4. DTurn the alarm volume down as low as it will go
5.实验室检查值与电解质中等

After surgery for colon cancer, a patient's CEA had fallen to normal, but it has been rising over the last two checks. What does this most likely suggest?

  1. AA sign of iron deficiency from the earlier bleeding
  2. BPossible recurrence that needs further assessment
  3. CA sure sign that the cancer has been fully cured
  4. DA normal change after surgery that needs no follow-up
6.实验室检查值与电解质困难

The nurse teaches a patient with chronic kidney disease about a potassium-restricted diet. Which statement shows a need for further teaching?

  1. A"Dried apricots and raisins will be a good snack for me now"
  2. B"I'll limit bananas, oranges and potatoes in my meals"
  3. C"I'll check food labels and ask my dietitian about portion sizes"
  4. D"I can leach potatoes by soaking them before cooking them"
7.临床护理中等

Long-term amiodarone treatment can affect which of the following?

  1. ABlood glucose and cholesterol only
  2. BThe sense of smell and taste only, with no other effects
  3. CThyroid function, the lungs and the skin's sensitivity to sunlight
  4. DHair colour and nail growth only, with no effect on organs
8.临床护理困难

A patient with a COPD exacerbation remains acidotic with a high PaCO2 despite optimal medical treatment and controlled oxygen. Which treatment is usually considered next?

  1. ASedation to slow the breathing
  2. BNon-invasive ventilation
  3. CStopping all oxygen therapy
  4. D15 L/min oxygen via a non-rebreathe mask
9.内外科护理：心血管与呼吸中等

After an acute coronary syndrome, a patient with a normal cholesterol level is prescribed a high-intensity statin. Why?

  1. AStatins are needed only if the cholesterol level is very high
  2. BStatins reduce further events whatever the starting cholesterol
  3. CStatins are given after an ACS mainly to lower the blood pressure
  4. DStatins work as painkillers for chest pain
10.内外科护理：心血管与呼吸困难

为什么高流量氧疗要使用湿化？

  1. A高流量的干燥气体会使气道干燥，分泌物变稠
  2. B水蒸气可滤除氧气供应中的细菌
  3. C湿化可防止氧中毒的发生
  4. D湿化的气体每升携带的氧气比干燥气体多
11.内外科护理：神经、内分泌与肾脏中等

卒中静脉溶栓前，通常采用哪个血压限值？

  1. A低于约 185/110 mmHg
  2. B低于约 90/60 mmHg
  3. C高于约 200/120 mmHg
  4. D没有血压限值
12.内外科护理：神经、内分泌与肾脏困难

A patient's potassium is 7.1 mmol/L, and the ECG shows peaked T waves and broad QRS complexes. What is the first treatment?

  1. AIV furosemide
  2. BOral potassium binder
  3. COral sodium bicarbonate
  4. DIV calcium gluconate
13.内外科护理：消化、围手术期与肿瘤中等

Why is a urinary catheter usually inserted in a patient with a major burn?

  1. AThe catheter prevents wound infection
  2. BHourly urine output guides fluid resuscitation
  3. CBurns always cause the bladder to rupture
  4. DIt is needed to give medicines into the bladder
14.内外科护理：消化、围手术期与肿瘤困难

一名患者正在接受负压伤口治疗。泵报警，敷料失去了密封。最恰当的措施是什么？

  1. A在泡沫上用干纱布填塞伤口，并用胶带贴紧
  2. B把泡沫留在伤口内、不吸引，直到数天后复查
  3. C恢复密封；如果及时无法恢复，改用湿性敷料
  4. D把吸力调到最大设置以拉回密封

3溶液

1.优先排序与委派

答案: D · Dark purple or black

为什么是这个答案

A healthy stoma is moist and pink to red, and early swelling or slight bleeding is common. A dark purple or black stoma suggests poor blood supply (ischemia) and needs urgent review.

答案

D · Dark purple or black
2.优先排序与委派

答案: C · Talk to the assistant privately, restate what must be reported and follow up closely

为什么是这个答案

The RN gives direct, private feedback, restates the reporting limits and increases supervision. If the problem continues, it is escalated to the manager according to policy.

答案

C · Talk to the assistant privately, restate what must be reported and follow up closely
3.感染控制与患者安全

答案: B · 暂停并重新核对医嘱和药物，然后再给药

为什么是这个答案

患者的疑虑是一次安全检查。护士应暂停并核对医嘱、药物、剂量和患者，必要时联系药房。有时原因是品牌不同，但必须先加以确认。

答案

B · 暂停并重新核对医嘱和药物，然后再给药
4.感染控制与患者安全

答案: C · Keep the alarm on, fix the cause such as electrode placement, and adjust limits only per policy

为什么是这个答案

Disabling alarms is a known cause of missed deterioration. Alarm fatigue is reduced by fixing causes such as poor skin preparation or old electrodes and by setting individual limits according to orders and policy.

答案

C · Keep the alarm on, fix the cause such as electrode placement, and adjust limits only per policy
5.实验室检查值与电解质

答案: B · Possible recurrence that needs further assessment

为什么是这个答案

CEA is not specific enough for screening, but a rising level after successful treatment can signal recurrence, so imaging and further assessment are usually arranged. Smoking and some benign conditions can also raise CEA.核对依据: CEA Test · MedlinePlus (NIH) (2026)

答案

B · Possible recurrence that needs further assessment
6.实验室检查值与电解质

答案: A · "Dried apricots and raisins will be a good snack for me now"

为什么是这个答案

Dried fruits such as apricots and raisins are very high in potassium and should be limited in kidney disease with hyperkalemia. Limiting high-potassium foods, leaching vegetables and reading labels are correct strategies.核对依据: Potassium in diet · MedlinePlus (NIH) (2026); Spironolactone · MedlinePlus (NIH) (2018)

答案

A · "Dried apricots and raisins will be a good snack for me now"
7.临床护理

答案: C · Thyroid function, the lungs and the skin's sensitivity to sunlight

为什么是这个答案

Amiodarone can cause hypo- or hyperthyroidism, pulmonary fibrosis, liver problems and photosensitivity. Regular monitoring of thyroid and liver function is needed.

答案

C · Thyroid function, the lungs and the skin's sensitivity to sunlight
8.临床护理

答案: B · Non-invasive ventilation

为什么是这个答案

In hypercapnic respiratory failure from COPD that persists despite treatment, non-invasive ventilation (bilevel positive pressure) supports ventilation and lowers PaCO2. Stopping oxygen would cause dangerous hypoxia.

答案

B · Non-invasive ventilation
9.内外科护理：心血管与呼吸

答案: B · Statins reduce further events whatever the starting cholesterol

为什么是这个答案

After ACS, high-intensity statin therapy reduces recurrent MI, stroke and death regardless of baseline cholesterol, partly by stabilising plaques. It is part of standard secondary prevention with antiplatelets, beta-blockers, ACE inhibitors and lifestyle change.

答案

B · Statins reduce further events whatever the starting cholesterol
10.内外科护理：心血管与呼吸

答案: A · 高流量的干燥气体会使气道干燥，分泌物变稠

为什么是这个答案

高流量干燥气体超出了鼻腔湿化的能力，导致黏膜干燥、分泌物变稠和不适。加温加湿的高流量系统可提高耐受性并帮助清除分泌物。

答案

A · 高流量的干燥气体会使气道干燥，分泌物变稠
11.内外科护理：神经、内分泌与肾脏

答案: A · 低于约 185/110 mmHg

为什么是这个答案

许多指南要求溶栓前血压低于 185/110 mmHg，溶栓后 24 小时内低于 180/105 mmHg，因为血压过高会增加出血性转化的风险。读数更高时应先谨慎降压。

答案

A · 低于约 185/110 mmHg
12.内外科护理：神经、内分泌与肾脏

答案: D · IV calcium gluconate

为什么是这个答案

ECG changes mean the heart is at risk. IV calcium is given first to stabilise the myocardium, followed by insulin with glucose (and often nebulised salbutamol) to shift potassium into cells. Binders or dialysis then remove it.

答案

D · IV calcium gluconate
13.内外科护理：消化、围手术期与肿瘤

答案: B · Hourly urine output guides fluid resuscitation

为什么是这个答案

Fluid formulas give an initial estimate; the rate is then adjusted to urine output, typically around 0.5 mL/kg/h in adults, along with other signs of perfusion.

答案

B · Hourly urine output guides fluid resuscitation
14.内外科护理：消化、围手术期与肿瘤

答案: C · 恢复密封；如果及时无法恢复，改用湿性敷料

为什么是这个答案

NPWT 需要气密的密封。如果密封或吸力丧失且不能及时恢复（许多指南规定约 2 小时内），应取出泡沫并换成标准敷料，以降低感染风险。安全间隔由制造商和当地指南规定。

答案

C · 恢复密封；如果及时无法恢复，改用湿性敷料

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