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 woman calls to say her husband suddenly has a drooping face and slurred speech. What should the nurse advise?

  1. ALet him lie down and see if it improves
  2. BBook an appointment with his doctor next week
  3. CCall emergency services now and note the time it started
  4. DDrive him to the hospital yourself after he has eaten dinner
2.优先排序与委派困难

一名头部受伤并伴有腿部骨折的患者正在接受监测。哪项发现是优先事项？

  1. A尽管刚用过镇痛药，腿痛仍为 6/10
  2. B肘部有一处小擦伤
  3. C患者要求吃点东西
  4. D格拉斯哥昏迷评分从 15 分降至 12 分
3.感染控制与患者安全中等

A nurse has been fit-tested for an N95 respirator. What should the nurse do each time it is put on?

  1. AMoisten the edges so it seals better
  2. BWear a surgical mask underneath it
  3. CArrange a new fit test
  4. DPerform a user seal check
4.感染控制与患者安全困难

A patient refuses to wear an identification wristband. What should the nurse do?

  1. AAccept the refusal and identify the patient by room number and bed space instead
  2. BStop giving the patient any care until they agree to wear the band
  3. CForce the band onto the patient’s wrist
  4. DExplain why it is needed, use other ID methods per policy and document
5.实验室检查值与电解质中等

一名因房颤服用华法林的患者 INR 为 5.2，无出血。护士最好的措施是什么？

  1. A给予双倍剂量
  2. B暂停华法林剂量并通知开医嘱者
  3. C给予通常的剂量，一个月后复查
  4. D建议患者从今天起不再吃绿叶蔬菜
6.实验室检查值与电解质困难

Three days after starting haloperidol, a patient has a temperature of 40 °C, severe muscle rigidity and confusion. Which laboratory result would the nurse expect?

  1. AA very low serum sodium
  2. BA very low white cell count
  3. CA very high serum lithium
  4. DA very high creatine kinase (CK)
7.临床护理中等

Why are patients encouraged to use an incentive spirometer after abdominal surgery?

  1. ATo encourage deep breaths that prevent atelectasis and chest infection
  2. BTo measure their lung function so the result can go in the discharge letter
  3. CTo strengthen the abdominal muscles around the wound
  4. DTo lower their heart rate before mobilising
8.临床护理困难

一名急性消化道出血患者心率 120 次/分，血压 90/60 mmHg。呼救后，护理的首要任务是什么？

  1. A鼓励患者独自走去洗手间
  2. B推迟处理，直到查看粪便颜色
  3. C给一顿丰盛的饭以恢复体力
  4. D建立大口径静脉通路，准备补液或输血
9.内外科护理：心血管与呼吸中等

A patient who had a leg amputation says they feel burning pain in the missing foot. What is the best response?

  1. ATell the patient the pain must be imaginary as the foot has gone
  2. BExplain that phantom limb pain is real and arrange treatment
  3. CAdvise that it will be ignored until it stops
  4. DExplain that burning pain in the missing foot shows wound infection
10.内外科护理：心血管与呼吸困难

A patient with severe COPD has increasing ankle oedema and a raised JVP, but no crackles and a normal left ventricle on echocardiography. Which condition is most likely?

  1. ADeep vein thrombosis
  2. BCor pulmonale
  3. CAortic stenosis
  4. DLeft ventricular failure
11.内外科护理：神经、内分泌与肾脏中等

A patient takes levodopa for Parkinson's disease. Which teaching point is correct?

  1. AThe drug cures the disease if taken for a full year
  2. BStop the drug for a day each week to avoid tolerance
  3. CThe tablets work best taken with a large steak dinner
  4. DLarge high-protein meals can reduce how well the drug works
12.内外科护理：神经、内分泌与肾脏困难

After removal of a cortisol-producing adrenal adenoma, why may the patient need hydrocortisone for months?

  1. AThe other adrenal gland has been suppressed
  2. BThe operation always removes both adrenal glands
  3. CThe tumour will grow back quickly without it
  4. DHydrocortisone helps the wound to heal
13.内外科护理：消化、围手术期与肿瘤中等

Which statement about corticosteroids in inflammatory bowel disease is correct?

  1. AThey are the best long-term maintenance treatment
  2. BThey are given only as a one-off injection
  3. CThey are used to induce remission, not for maintenance
  4. DThey cure the disease after one course
14.内外科护理：消化、围手术期与肿瘤困难

On the morning of elective hip surgery, a patient says she took her usual warfarin last night despite being told to stop. What should the nurse do?

  1. ATell her the surgery must be cancelled for a month
  2. BProceed with the usual checklist and say nothing
  3. CInform the surgical and anaesthetic teams, who will check the INR
  4. DGive a double dose of vitamin K by mouth without waiting for a prescription

3溶液

1.优先排序与委派

答案: C · Call emergency services now and note the time it started

为什么是这个答案

Stroke is time-critical. Emergency services can begin assessment on the way and take the patient to a stroke center; the time of onset guides treatment.

答案

C · Call emergency services now and note the time it started
2.优先排序与委派

答案: D · 格拉斯哥昏迷评分从 15 分降至 12 分

为什么是这个答案

GCS 下降提示颅内压升高，可能致命，需要紧急上报。骨折疼痛也需要处理，但不像这样威胁生命。

答案

D · 格拉斯哥昏迷评分从 15 分降至 12 分
3.感染控制与患者安全

答案: D · Perform a user seal check

为什么是这个答案

A fit test confirms that a model and size suit the person. A user seal check, breathing in and out to feel for leaks at the edges, is done every time the respirator is put on.

答案

D · Perform a user seal check
4.感染控制与患者安全

答案: D · Explain why it is needed, use other ID methods per policy and document

为什么是这个答案

The nurse explains how the band prevents errors. If the patient still refuses, the nurse follows policy for alternative identification using two identifiers, informs the team and documents it.

答案

D · Explain why it is needed, use other ID methods per policy and document
5.实验室检查值与电解质

答案: B · 暂停华法林剂量并通知开医嘱者

为什么是这个答案

INR 5.2 远高于目标，会增加出血风险。护士应暂停该剂量，检查有无出血迹象并通知开医嘱者，后者可能开较低剂量或维生素 K。核对依据: Prothrombin Time Test and INR (PT/INR) · MedlinePlus (NIH) (2024); Warfarin · MedlinePlus (NIH) (2026)

答案

B · 暂停华法林剂量并通知开医嘱者
6.实验室检查值与电解质

答案: D · A very high creatine kinase (CK)

为什么是这个答案

These signs suggest neuroleptic malignant syndrome, a medical emergency. Muscle rigidity releases CK, often to very high levels, and the white count is often raised. Myoglobin can damage the kidneys. The antipsychotic is stopped and supportive care is started.

答案

D · A very high creatine kinase (CK)
7.临床护理

答案: A · To encourage deep breaths that prevent atelectasis and chest infection

为什么是这个答案

Shallow breathing after surgery lets alveoli collapse, causing atelectasis and pneumonia. Deep-breathing exercises with an incentive spirometer help keep the lungs expanded.

答案

A · To encourage deep breaths that prevent atelectasis and chest infection
8.临床护理

答案: D · 建立大口径静脉通路，准备补液或输血

为什么是这个答案

心动过速和低血压提示大量失血。首先进行 ABCDE 评估、建立粗口径静脉通路、抽血（包括交叉配血）并进行复苏，随后行内镜检查。

答案

D · 建立大口径静脉通路，准备补液或输血
9.内外科护理：心血管与呼吸

答案: B · Explain that phantom limb pain is real and arrange treatment

为什么是这个答案

Phantom limb pain is common after amputation and arises from changes in nerves and the brain. It is real and treated with analgesia, including drugs for neuropathic pain, plus measures such as mirror therapy. It does not mean infection.

答案

B · Explain that phantom limb pain is real and arrange treatment
10.内外科护理：心血管与呼吸

答案: B · Cor pulmonale

为什么是这个答案

Chronic hypoxia in COPD causes pulmonary hypertension, which strains the right ventricle and leads to right heart failure with oedema and raised JVP. Management includes treating hypoxia (long-term oxygen if eligible), diuretics for oedema and optimising COPD treatment.

答案

B · Cor pulmonale
11.内外科护理：神经、内分泌与肾脏

答案: D · Large high-protein meals can reduce how well the drug works

为什么是这个答案

Protein-rich meals can compete with levodopa for absorption and entry into the brain, which reduces its effect. Patients are often advised to take doses at consistent times relative to meals. Levodopa controls symptoms but does not stop the disease.

答案

D · Large high-protein meals can reduce how well the drug works
12.内外科护理：神经、内分泌与肾脏

答案: A · The other adrenal gland has been suppressed

为什么是这个答案

Excess cortisol from the adenoma suppressed ACTH, so the remaining adrenal gland is shrunken and underactive. Steroid replacement is needed until it recovers, which can take months. Stopping too early risks adrenal crisis.

答案

A · The other adrenal gland has been suppressed
13.内外科护理：消化、围手术期与肿瘤

答案: C · They are used to induce remission, not for maintenance

为什么是这个答案

Steroids settle flares but are not effective or safe for maintenance because of side effects such as osteoporosis, diabetes and infection. Drugs such as aminosalicylates, immunomodulators or biologics maintain remission.

答案

C · They are used to induce remission, not for maintenance
14.内外科护理：消化、围手术期与肿瘤

答案: C · Inform the surgical and anaesthetic teams, who will check the INR

为什么是这个答案

Recent warfarin may leave the INR too high for safe surgery or a spinal anaesthetic. The team needs to know at once; they check the INR and decide whether to delay or reverse.

答案

C · Inform the surgical and anaesthetic teams, who will check the INR

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