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

Before giving a medication to a child, which check is especially important?

  1. AThat the dose is correct for the child’s weight
  2. BThat the medicine cup is the child’s favorite color
  3. CThat the parent agrees with the time it is given
  4. DThat the child likes the taste of the drug
2.优先排序与委派困难

Before surgery, a nurse is asked to witness a patient’s consent. The patient was given a sedative 30 minutes ago. What should the nurse do?

  1. AAsk a family member to sign on the patient’s behalf
  2. BWitness it and write “sedated” beside the signature
  3. CWitness it quickly before the sedative takes full effect
  4. DNot witness the consent and inform the surgeon
3.感染控制与患者安全中等

A confused patient keeps pulling at an IV line. Which is a less restrictive option to consider before wrist restraints?

  1. ATying both arms to the bed frame
  2. BCovering the site with a sleeve or using hand mitts with supervision
  3. CUsing a vest restraint in the chair so that the patient’s hands stay down
  4. DGiving a sedative every few hours
4.感染控制与患者安全困难

During a power cut in a US hospital, a ventilator must stay powered. Where should it be plugged in?

  1. AInto a red outlet connected to the emergency generator
  2. BInto any white outlet in the room
  3. CInto the outlet that is closest to the bed, whatever its color
  4. DInto an extension cord from the corridor
5.实验室检查值与电解质中等

A healthy patient has a mildly raised CK after running a marathon yesterday, without dark urine or symptoms. What is the most likely explanation?

  1. AStrenuous exercise raised CK from skeletal muscle
  2. BThe patient has developed acute hepatitis
  3. CAn acute myocardial infarction has occurred
  4. DThe patient has developed acute pancreatitis
6.实验室检查值与电解质困难

收到四项实验室结果。护士应首先处理哪一项？

  1. A一名昨天因肺炎入院的患者钠 137 mEq/L
  2. B一名糖尿病患者餐后血糖 140 mg/dL（7.8 mmol/L）
  3. C一名慢性肾脏病患者血红蛋白 11.8 g/dL（118 g/L）
  4. D一名 CKD 患者钾 6.6 mEq/L，新出现肌无力
7.临床护理中等

What should a nurse do during a generalised tonic-clonic seizure?

  1. AHold the limbs firmly to stop the jerking and prevent injury
  2. BProtect the head, time the seizure and do not put anything in the mouth
  3. CGive the patient a drink of water
  4. DPut a tongue depressor between the teeth so that the tongue is not bitten
8.临床护理困难

A nurse teaches a patient with a new ileostomy. Which statement shows a need for further teaching?

  1. A"My output will be firm and formed like before."
  2. B"I will drink extra fluids when it is hot."
  3. C"I will empty the bag when it is about a third to half full."
  4. D"My stoma should look pink or red and moist."
9.内外科护理：心血管与呼吸中等

A 34-year-old has hypertension that is hard to control and a low serum potassium without taking diuretics. Which cause should be considered?

  1. AEssential hypertension of ageing
  2. BPrimary hyperaldosteronism
  3. CIron-deficiency anaemia
  4. DHypothyroidism
10.内外科护理：心血管与呼吸困难

A patient with pneumonia has a heart rate of 118/min, BP 86/50 mmHg, RR 28/min and a high lactate. Sepsis is recognised. Which action should not be delayed?

  1. AGive oral antibiotics and reassess the next day
  2. BDelay fluids until a chest X-ray has been reported
  3. CWait for the sputum culture result before choosing an antibiotic
  4. DTake blood cultures and give IV antibiotics within the first hour
11.内外科护理：神经、内分泌与肾脏中等

A patient with Alzheimer's disease starts donepezil. Which side effects should the nurse look for?

  1. ADry mouth, constipation and a fast heart rate
  2. BWeight gain, high glucose and swollen ankles
  3. CNausea, diarrhoea and a slow heart rate
  4. DA persistent dry cough and a raised potassium
12.内外科护理：神经、内分泌与肾脏困难

一名患者的慢性低钠血症在 24 小时内从 115 纠正到 132 mmol/L。两天后他们出现言语含糊、吞咽困难和肢体无力。最可能的原因是什么？

  1. A渗透性脱髓鞘综合征
  2. B与血钠无关的新发卒中
  3. C摄入不足引起的低血糖
  4. D低钠血症的正常恢复
13.内外科护理：消化、围手术期与肿瘤中等

Which advice has good evidence for reducing cancer-related fatigue?

  1. ARegular light to moderate activity, such as walking
  2. BAvoiding all daily activities
  3. CDrinking several strong coffees every evening
  4. DComplete bed rest for the whole course of treatment
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 a good idea, as long as the patient is not told about it afterwards
  2. BDeceptive placebos are unethical and do not show pain is "fake"
  3. CIt should be done only for patients with chronic pain
  4. DIt is acceptable if a senior nurse gives the saline

3溶液

1.优先排序与委派

答案: A · That the dose is correct for the child’s weight

为什么是这个答案

Pediatric doses are usually calculated by weight, and errors can cause serious harm. The nurse checks the dose against the child’s weight and the safe range before giving it.

答案

A · That the dose is correct for the child’s weight
2.优先排序与委派

答案: D · Not witness the consent and inform the surgeon

为什么是这个答案

Valid consent requires a patient who can understand and decide. After a sedative this may not be possible, so the nurse does not witness it and informs the surgeon, who is responsible for obtaining consent.

答案

D · Not witness the consent and inform the surgeon
3.感染控制与患者安全

答案: B · Covering the site with a sleeve or using hand mitts with supervision

为什么是这个答案

Covering the line, keeping it out of view and using mitts while observing the patient can stop pulling without fully restricting movement. Restraints and sedation are used only if these fail.

答案

B · Covering the site with a sleeve or using hand mitts with supervision
4.感染控制与患者安全

答案: A · Into a red outlet connected to the emergency generator

为什么是这个答案

In US hospitals, red outlets are usually connected to the emergency generator. Life-support equipment is plugged into them, and battery backups are checked as part of emergency planning.

答案

A · Into a red outlet connected to the emergency generator
5.实验室检查值与电解质

答案: A · Strenuous exercise raised CK from skeletal muscle

为什么是这个答案

Strenuous exercise, IM injections and muscle trauma can raise CK from skeletal muscle. A very high CK with dark urine suggests rhabdomyolysis, and heart damage is assessed with troponin, not CK.

答案

A · Strenuous exercise raised CK from skeletal muscle
6.实验室检查值与电解质

答案: D · 一名 CKD 患者钾 6.6 mEq/L，新出现肌无力

为什么是这个答案

钾 6.6 mEq/L 伴肌无力可引起危及生命的心律失常。护士应立即安排心电监护并通知医疗人员。CKD 的轻度贫血和餐后血糖轻度升高是预期的；钠正常。

答案

D · 一名 CKD 患者钾 6.6 mEq/L，新出现肌无力
7.临床护理

答案: B · Protect the head, time the seizure and do not put anything in the mouth

为什么是这个答案

Remove nearby hazards, cushion the head, note the time and do not restrain or put objects in the mouth. Once jerking stops, place the patient in the recovery position and check the airway.

答案

B · Protect the head, time the seizure and do not put anything in the mouth
8.临床护理

答案: A · "My output will be firm and formed like before."

为什么是这个答案

Ileostomy output is liquid to porridge-like because it bypasses the colon. The other statements describe correct care: good hydration, emptying the bag before it is too heavy and recognising a healthy stoma.

答案

A · "My output will be firm and formed like before."
9.内外科护理：心血管与呼吸

答案: B · Primary hyperaldosteronism

为什么是这个答案

Excess aldosterone (for example from an adrenal adenoma, Conn's syndrome) causes sodium retention, hypertension and potassium loss. Young age, resistant hypertension and unexplained hypokalaemia suggest a secondary cause and need investigation.

答案

B · Primary hyperaldosteronism
10.内外科护理：心血管与呼吸

答案: D · Take blood cultures and give IV antibiotics within the first hour

为什么是这个答案

In sepsis with shock, blood cultures, IV antibiotics within the first hour, IV fluids, lactate measurement, oxygen if hypoxic and urine output monitoring are started together. Cultures should not delay antibiotics. Persistent hypotension may need vasopressors in critical care.

答案

D · Take blood cultures and give IV antibiotics within the first hour
11.内外科护理：神经、内分泌与肾脏

答案: C · Nausea, diarrhoea and a slow heart rate

为什么是这个答案

Donepezil is a cholinesterase inhibitor. Raised acetylcholine can cause nausea, vomiting, diarrhoea, vivid dreams and bradycardia, which can lead to dizziness or fainting.

答案

C · Nausea, diarrhoea and a slow heart rate
12.内外科护理：神经、内分泌与肾脏

答案: A · 渗透性脱髓鞘综合征

为什么是这个答案

慢性低钠血症的快速纠正会使脑细胞皱缩，并可损伤脑桥和其他区域的髓鞘。症状（构音障碍、吞咽困难、四肢轻瘫、“闭锁”状态）在数天后出现。这就是为什么要限制纠正速度并密切监测血钠。

答案

A · 渗透性脱髓鞘综合征
13.内外科护理：消化、围手术期与肿瘤

答案: A · Regular light to moderate activity, such as walking

为什么是这个答案

Exercise, matched to ability, reduces cancer-related fatigue. Pacing, prioritising activities, sleep routines and treating causes such as anaemia or depression also help.

答案

A · Regular light to moderate activity, such as walking
14.内外科护理：消化、围手术期与肿瘤

答案: B · 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

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

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