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

During labor, the nurse sees the umbilical cord in the vagina after the membranes rupture. What is the first action?

  1. AWait for the next contraction before acting
  2. BAsk the patient to walk around the room to bring the baby lower and speed up labor
  3. CPush the cord back into the uterus
  4. DRelieve pressure on the cord by lifting the presenting part with a gloved hand
2.优先排序与委派困难

在外科病房，护士应首先看哪位术后患者？

  1. A前列腺手术后行膀胱冲洗：尿液呈淡粉色，无血块
  2. B结肠造口术后 2 天：造口湿润呈粉红色，排出量少
  3. C颈动脉内膜切除术后 6 小时：颈部肿胀加重，诉吞咽困难
  4. D髋关节置换术后 2 天：活动时疼痛 5/10，1 小时前已给过镇痛药
3.感染控制与患者安全中等

A child has swallowed a button battery. Why is this urgent?

  1. AIt always passes through the gut without harm
  2. BIt is only harmful if several batteries are swallowed
  3. CThe only risk is poisoning from heavy metals years later
  4. DIt can burn through the lining of the esophagus within hours
4.感染控制与患者安全困难

A nurse teaches parents about firearm safety at home. Which statement shows a need for further teaching?

  1. A“We store the gun unloaded in a locked safe in the bedroom.”
  2. B“We will ask other parents about guns before play dates.”
  3. C“We keep all the ammunition locked away separately from the gun.”
  4. D“We keep the gun loaded in the nightstand, and the children know not to touch it.”
5.实验室检查值与电解质中等

A patient with type 2 diabetes has a target HbA1c below 7% (53 mmol/mol). Today's result is 7.8% (62 mmol/mol). What is the best interpretation?

  1. AThe result shows today's fasting glucose is above the target
  2. BGlucose control has been excellent for the past several months
  3. CAverage glucose over the past months has been above the target
  4. DThe patient has had frequent episodes of severe hypoglycemia
6.实验室检查值与电解质困难

一名心力衰竭患者服用赖诺普利、螺内酯和钾补充剂。今天钾为 6.0 mEq/L。最可能的解释是什么？

  1. A钾补充剂对血清水平没有影响
  2. B螺内酯导致钾丢失
  3. C同时服用了几种使钾升高的药物
  4. D赖诺普利降低钾
7.临床护理中等

Which factor is most likely to slow wound healing?

  1. AAdequate fluid intake
  2. BA diet rich in protein
  3. CGood blood glucose control
  4. DSmoking
8.临床护理困难

一名全髋关节置换术后的患者突然出现剧烈髋部疼痛，下肢缩短并发生旋转。最可能的并发症是什么？

  1. A尿潴留
  2. B小腿深静脉血栓形成
  3. C伤口感染
  4. D假体脱位
9.内外科护理：心血管与呼吸中等

A patient taking simvastatin drinks a large glass of grapefruit juice every morning. Why is this a concern?

  1. AIt turns the statin into a blood thinner
  2. BIt causes the cholesterol level to rise sharply
  3. CIt raises statin levels and the risk of muscle damage
  4. DIt stops the statin from being absorbed from the gut at all
10.内外科护理：心血管与呼吸困难

A patient with both COPD and heart disease is more breathless, with bilateral basal crackles, raised JVP, ankle swelling and a markedly raised NT-proBNP. Which problem is most likely driving this episode?

  1. AHyperventilation from anxiety
  2. BAn asthma attack
  3. CA primary spontaneous pneumothorax
  4. DDecompensated heart failure
11.内外科护理：神经、内分泌与肾脏中等

Before checking a capillary glucose, why should the patient wash their hands with soap and water?

  1. ASoap makes the blood flow faster from the finger
  2. BWashing lowers the glucose in the blood
  3. CWashing prevents all infection from the lancet
  4. DSugar on the skin can give a falsely high reading
12.内外科护理：神经、内分泌与肾脏困难

一名急性缺血性卒中患者不适合溶栓。第 1 天血压为 190/100 mmHg，没有其他紧急情况。通常哪种做法是恰当的？

  1. A每 5 分钟喷一次硝酸酯喷雾，直到低于 120 mmHg
  2. B让患者平躺并大量快速补液
  3. C用静脉药物迅速降至 110/70 mmHg
  4. D避免积极降压，遵循卒中团队的目标
13.内外科护理：消化、围手术期与肿瘤中等

对于小面积或散在的烧伤，哪个区域可用来快速估算 1% 的体表面积？

  1. A检查者的手掌（含手指）
  2. B患者的手和前臂
  3. C患者自己的手掌（含手指）
  4. D患者的拇指指甲
14.内外科护理：消化、围手术期与肿瘤困难

A patient on chemotherapy has white plaques on the tongue and cheeks that wipe off to leave red areas. What is most likely?

  1. AOral candidiasis
  2. BNormal mucositis healing
  3. CLeukoplakia from smoking
  4. DFood residue only

3溶液

1.优先排序与委派

答案: D · Relieve pressure on the cord by lifting the presenting part with a gloved hand

为什么是这个答案

In cord prolapse, the presenting part can compress the cord and cut off fetal oxygen. The nurse lifts the presenting part off the cord, calls for help and positions the patient (for example knee-chest) while urgent birth is arranged.

答案

D · Relieve pressure on the cord by lifting the presenting part with a gloved hand
2.优先排序与委派

答案: C · 颈动脉内膜切除术后 6 小时：颈部肿胀加重，诉吞咽困难

为什么是这个答案

颈动脉手术后颈部肿胀增大提示可能压迫气道的血肿。粉红湿润的造口以及冲洗时淡粉色的尿液是预期的，活动时中度疼痛也很常见。

答案

C · 颈动脉内膜切除术后 6 小时：颈部肿胀加重，诉吞咽困难
3.感染控制与患者安全

答案: D · It can burn through the lining of the esophagus within hours

为什么是这个答案

A button battery lodged in the esophagus can cause severe chemical burns within a few hours, so the child needs emergency assessment and often removal. It should never be treated as harmless.

答案

D · It can burn through the lining of the esophagus within hours
4.感染控制与患者安全

答案: D · “We keep the gun loaded in the nightstand, and the children know not to touch it.”

为什么是这个答案

Firearms in homes with children should be stored unloaded and locked, with ammunition stored separately and locked. Telling children not to touch a gun does not reliably prevent injuries.

答案

D · “We keep the gun loaded in the nightstand, and the children know not to touch it.”
5.实验室检查值与电解质

答案: C · Average glucose over the past months has been above the target

为什么是这个答案

An HbA1c of 7.8% shows that average glucose has been above the individual target over about 2–3 months. The nurse explores diet, activity, medication use and barriers, and the treatment plan may be adjusted.核对依据: Hemoglobin A1C (HbA1c) Test · MedlinePlus (NIH) (2025)

答案

C · Average glucose over the past months has been above the target
6.实验室检查值与电解质

答案: C · 同时服用了几种使钾升高的药物

为什么是这个答案

ACE 抑制剂和螺内酯都使肾脏潴留钾，而补充剂又增加了钾。护士应暂停补充剂，通知开医嘱者，并检查肾功能和心电图。核对依据: High potassium level · MedlinePlus (NIH) (2025); Spironolactone · MedlinePlus (NIH) (2018)

答案

C · 同时服用了几种使钾升高的药物
7.临床护理

答案: D · Smoking

为什么是这个答案

Smoking causes vasoconstriction and reduces tissue oxygen, slowing healing and increasing infection risk. Poor nutrition, diabetes, infection and steroids also impair healing.

答案

D · Smoking
8.临床护理

答案: D · 假体脱位

为什么是这个答案

关节置换术后髋关节脱位会引起突发疼痛、下肢缩短和旋转。需要紧急评估和复位；应教会患者活动注意事项。

答案

D · 假体脱位
9.内外科护理：心血管与呼吸

答案: C · It raises statin levels and the risk of muscle damage

为什么是这个答案

Grapefruit juice inhibits the CYP3A4 enzyme, increasing levels of drugs such as simvastatin and some calcium channel blockers. Higher statin levels raise the risk of myopathy. Patients are advised to avoid large amounts or choose a statin not affected.

答案

C · It raises statin levels and the risk of muscle damage
10.内外科护理：心血管与呼吸

答案: D · Decompensated heart failure

为什么是这个答案

Basal crackles, raised JVP, oedema and a high natriuretic peptide point to heart failure rather than a COPD exacerbation alone. Distinguishing them matters, because treatment (diuretics and HF drugs versus bronchodilators and steroids) is different. Both may occur together.

答案

D · Decompensated heart failure
11.内外科护理：神经、内分泌与肾脏

答案: D · Sugar on the skin can give a falsely high reading

为什么是这个答案

Traces of sugar on the fingers can falsely raise the reading. Hands are washed and dried before testing. The side of the fingertip is used, and lancets are single use.

答案

D · Sugar on the skin can give a falsely high reading
12.内外科护理：神经、内分泌与肾脏

答案: D · 避免积极降压，遵循卒中团队的目标

为什么是这个答案

缺血性卒中后，缺血半暗带依赖血压来灌注。除非计划溶栓或存在主动脉夹层、急性心力衰竭等其他紧急情况，指南通常在早期接受较高的血压（例如某些指南只在高于 220/120 mmHg 时才处理）。目标由卒中团队设定。

答案

D · 避免积极降压，遵循卒中团队的目标
13.内外科护理：消化、围手术期与肿瘤

答案: C · 患者自己的手掌（含手指）

为什么是这个答案

患者并拢手指的手掌约占其体表总面积的 1%。这对小面积或不规则的烧伤很有用。单纯红斑（浅表烧伤）不计入总数。

答案

C · 患者自己的手掌（含手指）
14.内外科护理：消化、围手术期与肿瘤

答案: A · Oral candidiasis

为什么是这个答案

Oral thrush is common during chemotherapy, especially with steroids or antibiotics. It is reported so that antifungal treatment can be prescribed, and good oral care continues.

答案

A · Oral candidiasis

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