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 at 35 weeks of pregnancy with high blood pressure calls the clinic. Which symptom needs urgent assessment?

  1. AMild ankle swelling at the end of the day
  2. BBackache after a long walk
  3. CNeeding to pass urine more often
  4. DA severe headache with blurred vision
2.优先排序与委派困难

A patient with SIADH has a serum sodium of 120 mEq/L and is newly confused. Which nursing action has priority?

  1. AHelping the patient to walk in the corridor alone
  2. BEncouraging the patient to drink plenty of water
  3. CSeizure precautions and close neurological checks
  4. DTeaching the patient about a low-sodium diet at home
3.感染控制与患者安全中等

A patient with a fentanyl skin patch wants to use a heating pad on the area. What should the nurse teach?

  1. AHeat makes the patch last longer, so fewer patches are needed each month
  2. BHeat only matters if the patch is on the chest
  3. CAvoid heat on or near the patch, because it increases how fast the drug is absorbed
  4. DHeat is fine to use, because it helps the patch stick better to the skin
4.感染控制与患者安全困难

Over a few hours, the emergency department sees many previously healthy people with the same unusual severe symptoms. What should the nurse do?

  1. AReport it to infection prevention and public health authorities promptly
  2. BSend the patients home quickly to avoid crowding the emergency department
  3. CTreat each patient and wait to see if more arrive next week
  4. DTell only the patients’ families about the pattern
5.实验室检查值与电解质中等

A healthy patient's result is slightly outside the laboratory reference range, and all other results are normal. Which statement best explains why this can happen?

  1. ARanges cover about 95% of healthy people, so some fall outside
  2. BAny result outside the range always means disease is present
  3. CReference ranges are the same in every laboratory worldwide
  4. DReference ranges include every healthy person without exception
6.实验室检查值与电解质困难

A health care worker's hepatitis B tests show: HBsAg negative, anti-HBs positive, anti-HBc positive. What does this mean?

  1. ANot immune and never exposed to the virus
  2. BImmunity from vaccination only, never infected
  3. CPast infection that has resolved, with immunity
  4. DCurrent chronic hepatitis B infection
7.临床护理中等

慢性肾病患者的饮食通常需要限制什么？

  1. A完全不吃碳水化合物
  2. B维生素 C 和膳食纤维
  3. C钾和磷
  4. D只限水溶性维生素
8.临床护理困难

A patient on metformin with reduced kidney function is due a CT scan with IV contrast. Why might metformin be withheld?

  1. AMetformin makes the images blurry
  2. BMetformin causes severe bleeding during scans
  3. CMetformin reacts with the contrast to cause severe hyperglycaemia
  4. DThere is a risk of lactic acidosis if kidney function worsens
9.内外科护理：心血管与呼吸中等

Which foot care advice is correct for a patient with peripheral arterial disease?

  1. AWalk barefoot at home to strengthen the feet
  2. BCut corns with a razor blade to prevent pressure
  3. CUse a hot water bottle on the feet at night
  4. DCheck the feet daily and wear well-fitting shoes
10.内外科护理：心血管与呼吸困难

Which task for a stable patient with heart failure can the registered nurse most appropriately delegate to a healthcare assistant (unlicensed assistive personnel)?

  1. AMeasuring and recording the morning weight
  2. BTeaching the patient about a low-salt diet
  3. CDeciding whether to give the furosemide dose
  4. DAssessing lung sounds for new crackles
11.内外科护理：神经、内分泌与肾脏中等

A patient with migraine takes painkillers or triptans on most days and now has a headache almost every day. What is the likely problem?

  1. AMedication overuse headache
  2. BAn allergy to the painkillers
  3. CA brain tumour, which is almost certain
  4. DNormal progress of migraine
12.内外科护理：神经、内分泌与肾脏困难

The nurse has four endocrine patients. Which one needs to be seen first?

  1. AA patient with hyperthyroidism who is confused, with a temperature of 39.5 °C (103.1 °F)
  2. BA patient with hypothyroidism who has been constipated for three days
  3. CA patient after thyroidectomy with mild pain on swallowing
  4. DA patient with Graves' disease asking about radioactive iodine
13.内外科护理：消化、围手术期与肿瘤中等

What is TENS?

  1. AA device that sends mild electrical pulses through skin pads
  2. BA strong opioid given through the skin as a weekly adhesive patch
  3. CA pain score used for babies
  4. DA type of epidural catheter inserted in theatre
14.内外科护理：消化、围手术期与肿瘤困难

外科病房有四位患者。护士应首先评估哪位患者？

  1. A中性粒细胞减少：一小时前体温正常，感觉良好
  2. B肠道手术后四小时：脉搏 118 次/分，血压 90/55 mmHg
  3. C稳定的回肠造口：请求帮助更换造口袋
  4. D术后第 3 天：因便秘要求使用泻药

3溶液

1.优先排序与委派

答案: D · A severe headache with blurred vision

为什么是这个答案

A severe headache and visual changes can be signs of severe pre-eclampsia and a risk of eclampsia. Mild ankle swelling, backache and frequent urination are common in late pregnancy.

答案

D · A severe headache with blurred vision
2.优先排序与委派

答案: C · Seizure precautions and close neurological checks

为什么是这个答案

Severe hyponatremia can cause seizures and falls. The nurse keeps the patient safe and reports changes; free water is restricted rather than encouraged, as prescribed.

答案

C · Seizure precautions and close neurological checks
3.感染控制与患者安全

答案: C · Avoid heat on or near the patch, because it increases how fast the drug is absorbed

为什么是这个答案

Heat from heating pads, electric blankets, hot tubs or fever increases fentanyl absorption and can cause an overdose. Patients are taught to avoid heat over the patch.

答案

C · Avoid heat on or near the patch, because it increases how fast the drug is absorbed
4.感染控制与患者安全

答案: A · Report it to infection prevention and public health authorities promptly

为什么是这个答案

Clusters of similar unusual illness can signal an outbreak or bioterrorism. Early reporting allows public health to investigate, guide precautions and treatment, and protect the community.

答案

A · Report it to infection prevention and public health authorities promptly
5.实验室检查值与电解质

答案: A · Ranges cover about 95% of healthy people, so some fall outside

为什么是这个答案

A reference range is usually the central 95% of results from a healthy population, so about 1 in 20 healthy people will have a value just outside it. The result is interpreted with the clinical picture and previous values, and repeated if needed.核对依据: How to Understand Your Lab Results · MedlinePlus (NIH) (2025)

答案

A · Ranges cover about 95% of healthy people, so some fall outside
6.实验室检查值与电解质

答案: C · Past infection that has resolved, with immunity

为什么是这个答案

The vaccine contains only surface antigen, so vaccination produces anti-HBs alone. A positive anti-HBc shows past or current infection; with HBsAg negative and anti-HBs positive, the infection has cleared and the person is immune.核对依据: Hepatitis Testing · MedlinePlus (NIH)

答案

C · Past infection that has resolved, with immunity
7.临床护理

答案: C · 钾和磷

为什么是这个答案

受损的肾脏难以排出钾和磷，因此常需要饮食限制，同时限制盐，有时还要限制液体和蛋白质。

答案

C · 钾和磷
8.临床护理

答案: D · There is a risk of lactic acidosis if kidney function worsens

为什么是这个答案

Iodinated contrast can worsen kidney function, and metformin can then accumulate and cause lactic acidosis. Local policy guides when to stop and restart it.

答案

D · There is a risk of lactic acidosis if kidney function worsens
9.内外科护理：心血管与呼吸

答案: D · Check the feet daily and wear well-fitting shoes

为什么是这个答案

Reduced blood flow slows healing, so minor injuries can become ulcers or gangrene. Patients inspect their feet daily, keep them clean and moisturised, wear well-fitting footwear and see a podiatrist for nails and corns. Direct heat can burn ischaemic skin.

答案

D · Check the feet daily and wear well-fitting shoes
10.内外科护理：心血管与呼吸

答案: A · Measuring and recording the morning weight

为什么是这个答案

Weighing a stable patient is a routine, measurable task that can be delegated, with the result reported to the nurse. Assessment, patient teaching and clinical decisions about medicines require the registered nurse's judgement and cannot be delegated.

答案

A · Measuring and recording the morning weight
11.内外科护理：神经、内分泌与肾脏

答案: A · Medication overuse headache

为什么是这个答案

Frequent use of painkillers or triptans can cause medication overuse headache. Treatment involves withdrawing the overused drug under guidance and starting a preventive treatment if needed.

答案

A · Medication overuse headache
12.内外科护理：神经、内分泌与肾脏

答案: A · A patient with hyperthyroidism who is confused, with a temperature of 39.5 °C (103.1 °F)

为什么是这个答案

Fever and confusion in a patient with hyperthyroidism suggest thyroid storm, which can be fatal without urgent treatment. The other problems are expected or non-urgent.

答案

A · A patient with hyperthyroidism who is confused, with a temperature of 39.5 °C (103.1 °F)
13.内外科护理：消化、围手术期与肿瘤

答案: A · A device that sends mild electrical pulses through skin pads

为什么是这个答案

TENS is thought to reduce pain partly through the gate-control mechanism. It is non-invasive and patient-controlled, but is avoided over certain areas and with some implanted devices.

答案

A · A device that sends mild electrical pulses through skin pads
14.内外科护理：消化、围手术期与肿瘤

答案: B · 肠道手术后四小时：脉搏 118 次/分，血压 90/55 mmHg

为什么是这个答案

术后早期出现心动过速伴低血压，提示出血或脓毒症，需要立即评估和上报。其他患者目前情况稳定，不过中性粒细胞减少的患者仍需要定期监测。

答案

B · 肠道手术后四小时：脉搏 118 次/分，血压 90/55 mmHg

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