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 nurse needs to give report on a patient to a colleague. Which information is the most important to include?

  1. APersonal opinions about the patient’s family members and their visiting habits
  2. BThe patient’s current condition, recent changes and pending tasks
  3. CThe patient’s favorite television programs and hobbies
  4. DDetails of the nurse’s own break times that shift
2.优先排序与委派困难

Several patients on a unit develop diarrhea within two days. What should the nurse do first?

  1. AWait to see if more patients become unwell
  2. BGive all patients antidiarrheal drugs without assessment
  3. CPlace affected patients on contact precautions and inform infection control
  4. DMove the affected patients into shared rooms with other patients to free up beds
3.感染控制与患者安全中等

Before inserting a peripheral IV, the nurse cleans the skin with chlorhexidine-alcohol. What should the nurse do next?

  1. ALet it dry fully and do not touch the site again
  2. BWipe it off with a dry gauze straight away
  3. CFeel for the vein again with an ungloved finger
  4. DBlow on the site so it dries faster
4.感染控制与患者安全困难

A nurse has weeping dermatitis on both hands. What is the most appropriate action?

  1. AAvoid direct patient care and handling of equipment until it heals, and see occupational health
  2. BUse extra alcohol hand rub on the lesions
  3. CCover the lesions with a waterproof bandage and keep working with patients as usual
  4. DContinue care as usual and wear one pair of gloves
5.实验室检查值与电解质中等

A patient with acute pancreatitis has muscle twitching and numbness around the mouth. Which laboratory value should the nurse check?

  1. ASerum chloride
  2. BSerum amylase
  3. CSerum calcium
  4. DSerum sodium
6.实验室检查值与电解质困难

A patient with advanced chronic kidney disease has a mildly raised troponin that has stayed the same on several tests over months. There is no chest pain and the ECG is unchanged. What is the best interpretation?

  1. AProof of an acute myocardial infarction that needs emergency treatment now
  2. BA chronic stable rise; infarction needs a rising or falling pattern
  3. CA sign of skeletal muscle injury, because troponin comes from all muscles
  4. DA laboratory error, because troponin is never raised in kidney disease
7.临床护理中等

Why are alternate sutures sometimes removed first when taking out stitches?

  1. ATo make the procedure faster
  2. BTo check the wound stays closed before removing the rest
  3. CTo reduce the cost of dressings
  4. DBecause the remaining sutures dissolve on their own within a day
8.临床护理困难

A patient admitted after a fall takes many regular medicines. Which safety step on admission helps prevent medication errors?

  1. APrescribing only the medicines that the patient can remember taking
  2. BStopping all regular medicines until the day the patient is discharged
  3. CDoubling the doses to make up for any missed while at home
  4. DMedicines reconciliation against reliable sources, such as primary care records
9.内外科护理：心血管与呼吸中等

为什么胸腔引流管通常不应夹闭？

  1. A夹闭会使管子永久变脆开裂
  2. B夹闭会使胸腔内液体引流得过快
  3. C夹闭会使水封瓶中的水蒸发
  4. D滞留的空气会积聚，导致张力性气胸
10.内外科护理：心血管与呼吸困难

A conscious adult in the dining room is suddenly unable to speak, cough or breathe after a mouthful of food. What should the nurse do first?

  1. ASweep blindly in the mouth with a finger
  2. BUp to five back blows, then up to five abdominal thrusts if needed
  3. CEncourage them to drink a glass of water to wash the food down
  4. DLie them down on the floor and start chest compressions immediately
11.内外科护理：神经、内分泌与肾脏中等

甲状腺切除术后，为什么常在床边备有拆线或拆夹器？

  1. A必须在术后第一天晚上拆线
  2. B颈部血肿可压迫气道，可能需要松解
  3. C用于从颈静脉抽血
  4. D用于在引流管不通时调整引流管
12.内外科护理：神经、内分泌与肾脏困难

A patient with myasthenia gravis took extra pyridostigmine doses. They now have more weakness, heavy salivation, sweating, diarrhoea, small pupils and a slow pulse. What is most likely?

  1. AA normal response to a higher dose
  2. BA cholinergic crisis from too much medication
  3. CA myasthenic crisis from too little medication
  4. DAn allergic reaction to the drug
13.内外科护理：消化、围手术期与肿瘤中等

Why are urinary catheters removed as early as possible after surgery?

  1. ABecause the catheter stops the bowel working
  2. BTo reduce the risk of catheter-associated infection
  3. CBecause catheters always cause kidney stones
  4. DBecause patients cannot drink normally while a catheter is in place
14.内外科护理：消化、围手术期与肿瘤困难

During burn resuscitation, a 70 kg adult's urine output has been 120 mL/h for 3 hours, and the face and limbs are very oedematous. What should the nurse do?

  1. ADiscuss reducing the fluid rate with the team
  2. BStop all IV fluids completely and remove the catheter
  3. CIncrease the fluid rate to keep the output high
  4. DGive a diuretic without discussing it

3溶液

1.优先排序与委派

答案: B · The patient’s current condition, recent changes and pending tasks

为什么是这个答案

Effective handover covers the current status, changes, risks and outstanding tasks, often using a structure such as SBAR. Opinions and unrelated details distract from what matters.

答案

B · The patient’s current condition, recent changes and pending tasks
2.优先排序与委派

答案: C · Place affected patients on contact precautions and inform infection control

为什么是这个答案

A cluster of diarrhea may be an outbreak, for example of C. difficile or norovirus. Contact precautions and early notification of infection control limit spread.

答案

C · Place affected patients on contact precautions and inform infection control
3.感染控制与患者安全

答案: A · Let it dry fully and do not touch the site again

为什么是这个答案

Chlorhexidine-alcohol must dry completely to kill organisms effectively. Touching the site after cleaning contaminates it, so the vein is located before prepping or with a sterile glove.

答案

A · Let it dry fully and do not touch the site again
4.感染控制与患者安全

答案: A · Avoid direct patient care and handling of equipment until it heals, and see occupational health

为什么是这个答案

Weeping skin lesions increase the risk of passing organisms to patients and of the nurse picking up bloodborne pathogens. The nurse should avoid direct patient contact and handling of patient equipment until the condition is assessed and resolved.

答案

A · Avoid direct patient care and handling of equipment until it heals, and see occupational health
5.实验室检查值与电解质

答案: C · Serum calcium

为什么是这个答案

In severe pancreatitis, fatty acids released from damaged fat bind calcium (saponification), causing hypocalcemia. Twitching and perioral numbness are signs of low calcium, which can progress to tetany and seizures.核对依据: Calcium Blood Test · MedlinePlus (NIH) (2024)

答案

C · Serum calcium
6.实验室检查值与电解质

答案: B · A chronic stable rise; infarction needs a rising or falling pattern

为什么是这个答案

Troponin is often chronically raised in CKD and other conditions. Acute infarction is diagnosed by a rise and/or fall in troponin together with symptoms or ECG changes, so serial results are compared with the patient's baseline.核对依据: Troponin Test · MedlinePlus (NIH) (2023)

答案

B · A chronic stable rise; infarction needs a rising or falling pattern
7.临床护理

答案: B · To check the wound stays closed before removing the rest

为什么是这个答案

Removing alternate sutures allows the nurse to see whether the wound edges stay together. If they begin to separate, the remaining sutures can be left and the team informed.

答案

B · To check the wound stays closed before removing the rest
8.临床护理

答案: D · Medicines reconciliation against reliable sources, such as primary care records

为什么是这个答案

Medicines reconciliation compares several sources to produce an accurate medication list. It finds omissions, duplications and errors, and is especially important in older people with polypharmacy.

答案

D · Medicines reconciliation against reliable sources, such as primary care records
9.内外科护理：心血管与呼吸

答案: D · 滞留的空气会积聚，导致张力性气胸

为什么是这个答案

在肺仍漏气时夹闭引流管，会使胸膜腔内压力升高，可导致张力性气胸。仅在特定情况下（如更换装置）短暂夹闭，并且必须遵医嘱。

答案

D · 滞留的空气会积聚，导致张力性气胸
10.内外科护理：心血管与呼吸

答案: B · Up to five back blows, then up to five abdominal thrusts if needed

为什么是这个答案

For a conscious adult with severe choking, current UK, European and AHA (2025) guidance teach up to five back blows, then up to five abdominal thrusts, repeated until the obstruction clears; some older courses used abdominal thrusts alone. If the person becomes unconscious, CPR is started. Blind finger sweeps can push the object further in.

答案

B · Up to five back blows, then up to five abdominal thrusts if needed
11.内外科护理：神经、内分泌与肾脏

答案: B · 颈部血肿可压迫气道，可能需要松解

为什么是这个答案

甲状腺手术后颈部血肿可迅速压迫气道。许多病房在床边备有拆夹器或拆线器及气道设备，以便在紧急情况下打开伤口。护士应观察有无肿胀、喘鸣和呼吸困难。

答案

B · 颈部血肿可压迫气道，可能需要松解
12.内外科护理：神经、内分泌与肾脏

答案: B · A cholinergic crisis from too much medication

为什么是这个答案

Too much cholinesterase inhibitor causes a cholinergic crisis: weakness plus muscarinic effects such as salivation, sweating, diarrhoea, miosis and bradycardia. A myasthenic crisis is weakness from under-treatment or triggers. Both can cause respiratory failure, so the airway is the priority.

答案

B · A cholinergic crisis from too much medication
13.内外科护理：消化、围手术期与肿瘤

答案: B · To reduce the risk of catheter-associated infection

为什么是这个答案

The risk of catheter-associated urinary tract infection increases with duration. Daily review of the need for a catheter, and early removal, reduce infection and help mobilisation.

答案

B · To reduce the risk of catheter-associated infection
14.内外科护理：消化、围手术期与肿瘤

答案: A · Discuss reducing the fluid rate with the team

为什么是这个答案

An output of about 1.7 mL/kg/h suggests over-resuscitation. Excess fluid ("fluid creep") worsens oedema and can cause pulmonary oedema and compartment syndromes, so the rate is reviewed and reduced under the burn protocol.

答案

A · Discuss reducing the fluid rate with the team

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