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

A nurse has given rapid-acting insulin, and then learns that the patient’s meal tray will be 45 minutes late. What should the nurse do?

  1. ATell the patient to wait and do nothing until the tray comes
  2. BGive a second, smaller dose of insulin when the meal tray finally arrives
  3. CAsk the patient to walk around the ward until the food arrives
  4. DGet the patient some carbohydrate food now and check the glucose
2.优先排序与委派困难

Which patient with cirrhosis should the nurse see first?

  1. ALarge ascites that is unchanged from yesterday
  2. BVomiting bright red blood, heart rate 120/min
  3. CWants to talk about stopping drinking alcohol for good
  4. DLong-standing jaundice and itchy skin, asking for cream
3.感染控制与患者安全中等

A patient with a severe latex allergy is booked for surgery. Which measure is commonly used?

  1. AUse latex gloves only for short procedures
  2. BGive the patient antihistamines before surgery and then use the normal supplies
  3. CWrap latex items in plastic before use
  4. DUse latex-free supplies and schedule the patient as the first case of the day
4.感染控制与患者安全困难

A patient’s WBC is 4,000/mm3, with 30% neutrophils and 5% bands. What is the absolute neutrophil count (ANC)?

  1. A1,200/mm3
  2. B140/mm3
  3. C3,500/mm3
  4. D1,400/mm3
5.实验室检查值与电解质中等

A patient taking empagliflozin (an SGLT2 inhibitor) has glucose in the urine but a normal blood glucose. What is the best interpretation?

  1. AUncontrolled diabetes needing insulin
  2. BA sign of kidney failure
  3. CAn expected effect of the drug
  4. DA urinary tract infection
6.实验室检查值与电解质困难

A patient on lithium has had vomiting and diarrhea for 3 days and has been taking ibuprofen. They now have a coarse tremor and confusion. The lithium level is 2.2 mEq/L. What is the best interpretation and action?

  1. AA normal level; continue lithium as prescribed
  2. BA low level; ask for the lithium dose to be raised
  3. CLithium toxicity; hold lithium and report urgently
  4. DIbuprofen side effects only; give it with food
7.临床护理中等

Which mask is required for staff during an aerosol-generating procedure on a patient with a respiratory infection spread by aerosols?

  1. ANo mask, as long as gloves are worn
  2. BA cloth face covering
  3. CA standard fluid-repellent surgical mask with a visor
  4. DA fit-tested respirator mask (such as FFP3 or N95)
8.临床护理困难

A patient suddenly develops a severe "worst ever" headache that reached full intensity within seconds, followed by vomiting and neck stiffness. What should be suspected?

  1. ASubarachnoid haemorrhage
  2. BMigraine with aura in a known migraine sufferer
  3. CTension headache
  4. DSinusitis
9.内外科护理：心血管与呼吸中等

A patient with an implantable cardioverter-defibrillator asks what to do if it fires. Which teaching is correct?

  1. AOne shock and well: contact the device clinic; repeated shocks or unwell: call emergency services
  2. BIgnore any shock at all, because the device is designed to fire every day and needs no follow-up
  3. CDrive straight to hospital alone after any shock so the device can be checked by the team
  4. DRemove the device battery at home if it fires more than once
10.内外科护理：心血管与呼吸困难

An adult inhales a peanut while laughing and now has a persistent cough and wheeze on one side. Where is the peanut most likely to have lodged?

  1. AThe left main bronchus
  2. BThe right main bronchus
  3. CThe oesophagus
  4. DThe nasal cavity
11.内外科护理：神经、内分泌与肾脏中等

垂体手术后，一名患者三小时内每小时排尿 400 mL，尿比重低。护士应怀疑什么？

  1. A尿崩症
  2. BSIADH
  3. C正常利尿
  4. D急性肾损伤
12.内外科护理：神经、内分泌与肾脏困难

A patient with nephrotic syndrome suddenly has loin pain, blood in the urine and a rise in creatinine. What is a likely cause?

  1. ANormal fluctuation in the disease
  2. BA simple bladder infection
  3. CRenal vein thrombosis
  4. DToo much dietary protein
13.内外科护理：消化、围手术期与肿瘤中等

Why is IV albumin often given after a large-volume paracentesis?

  1. ATo prevent low blood pressure and kidney injury from fluid shifts
  2. BTo raise the blood glucose after the procedure
  3. CTo replace the clotting factors and platelets lost in the drained fluid
  4. DTo treat infection in the ascitic fluid
14.内外科护理：消化、围手术期与肿瘤困难

Which group of signs suggests that a patient is entering the last days of life?

  1. AHigh blood pressure and very fast weight gain
  2. BRising appetite, more energy and normal skin colour and warmth
  3. CReduced intake, mottled skin and changes in breathing
  4. DClearer thinking and increased movement

3溶液

1.优先排序与委派

答案: D · Get the patient some carbohydrate food now and check the glucose

为什么是这个答案

Rapid-acting insulin starts working within minutes, so a long delay before eating risks hypoglycemia. The nurse arranges food or carbohydrate now and monitors the glucose.

答案

D · Get the patient some carbohydrate food now and check the glucose
2.优先排序与委派

答案: B · Vomiting bright red blood, heart rate 120/min

为什么是这个答案

Vomiting blood with a fast pulse suggests bleeding esophageal varices, which can quickly be fatal. The other findings are chronic or stable.

答案

B · Vomiting bright red blood, heart rate 120/min
3.感染控制与患者安全

答案: D · Use latex-free supplies and schedule the patient as the first case of the day

为什么是这个答案

Latex proteins can become airborne on glove powder and settle in the room. Using a latex-safe room and supplies and scheduling the patient first, when airborne latex is lowest, reduce the risk.

答案

D · Use latex-free supplies and schedule the patient as the first case of the day
4.感染控制与患者安全

答案: D · 1,400/mm3

为什么是这个答案

ANC = 4,000 × (0.30 + 0.05) = 1,400/mm3. This is below normal (neutropenia), so the patient has a raised risk of infection.

答案

D · 1,400/mm3
5.实验室检查值与电解质

答案: C · An expected effect of the drug

为什么是这个答案

SGLT2 inhibitors block glucose reabsorption in the proximal tubule, so glycosuria is expected even with normal blood glucose. Urine glucose cannot be used to monitor control in these patients. The drugs also raise the risk of genital infections and DKA.

答案

C · An expected effect of the drug
6.实验室检查值与电解质

答案: C · Lithium toxicity; hold lithium and report urgently

为什么是这个答案

A level of 2.2 mEq/L with coarse tremor and confusion is lithium toxicity. Fluid loss and NSAIDs both reduce lithium excretion by the kidneys. The dose is held, the provider is informed at once, and fluids and close monitoring are expected; severe cases may need dialysis.

答案

C · Lithium toxicity; hold lithium and report urgently
7.临床护理

答案: D · A fit-tested respirator mask (such as FFP3 or N95)

为什么是这个答案

Aerosol-generating procedures, such as intubation, release small infectious particles. Respirators that are fit-tested protect the wearer, while surgical masks mainly protect against droplets.

答案

D · A fit-tested respirator mask (such as FFP3 or N95)
8.临床护理

答案: A · Subarachnoid haemorrhage

为什么是这个答案

A sudden thunderclap headache suggests bleeding into the subarachnoid space, often from a ruptured aneurysm. It needs an urgent CT scan and neurosurgical input.

答案

A · Subarachnoid haemorrhage
9.内外科护理：心血管与呼吸

答案: A · One shock and well: contact the device clinic; repeated shocks or unwell: call emergency services

为什么是这个答案

A single shock with full recovery usually needs a call to the device team. Several shocks in a short time, or a shock with chest pain, breathlessness or collapse, needs emergency help. Patients should not drive themselves after a shock.

答案

A · One shock and well: contact the device clinic; repeated shocks or unwell: call emergency services
10.内外科护理：心血管与呼吸

答案: B · The right main bronchus

为什么是这个答案

Inhaled foreign bodies most often enter the right main bronchus and right lower lobe, because the right bronchus is wider, shorter and more vertical. Signs include a unilateral wheeze, reduced breath sounds and recurrent infection. Bronchoscopy is used for removal.

答案

B · The right main bronchus
11.内外科护理：神经、内分泌与肾脏

答案: A · 尿崩症

为什么是这个答案

垂体后叶或下丘脑受损可使 ADH 释放停止，引起中枢性尿崩症，排出大量稀释尿。护士应上报，密切监测液体平衡和血清钠，并预期使用去氨加压素治疗。

答案

A · 尿崩症
12.内外科护理：神经、内分泌与肾脏

答案: C · Renal vein thrombosis

为什么是这个答案

Loss of anticoagulant proteins in nephrotic syndrome raises the risk of thrombosis, including in the renal vein. This can cause loin pain, haematuria and worse kidney function. Imaging and anticoagulation are needed.

答案

C · Renal vein thrombosis
13.内外科护理：消化、围手术期与肿瘤

答案: A · To prevent low blood pressure and kidney injury from fluid shifts

为什么是这个答案

Removing large volumes of ascites can lead to hypotension and kidney injury as fluid moves from the blood into the abdomen. Albumin keeps fluid in the circulation; BP and urine output are monitored.

答案

A · To prevent low blood pressure and kidney injury from fluid shifts
14.内外科护理：消化、围手术期与肿瘤

答案: C · Reduced intake, mottled skin and changes in breathing

为什么是这个答案

Signs include increasing drowsiness, reduced intake, mottled cool peripheries, changes in breathing such as pauses, and noisy secretions. Recognising them allows care to focus on comfort and family support.

答案

C · Reduced intake, mottled skin and changes in breathing

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