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 had a colostomy formed yesterday. Which stoma appearance should be reported straight away?

  1. AMoist and pink-red
  2. BSlightly swollen
  3. CDark purple or black
  4. DA little bleeding when cleaned
2.优先排序与委派困难

A patient has a wrist restraint. The nurse finds the fingers on that hand pale, cool and tingling. What should the nurse do first?

  1. ADocument the finding and continue with the medication round
  2. BTighten the restraint so the patient moves less
  3. CRaise the arm on a pillow and check again in two hours
  4. DLoosen the restraint and assess the circulation
3.感染控制与患者安全中等

An adult with hepatitis A is incontinent of stool. Which precautions are used?

  1. AContact precautions in addition to standard precautions
  2. BDroplet precautions with a surgical mask
  3. CA protective environment with filtered air
  4. DAirborne precautions in a negative-pressure room with the door closed
4.感染控制与患者安全困难

A patient on chemotherapy develops shingles over several areas on both sides of the body. Which precautions are needed?

  1. AContact precautions only, with gloves for dressing changes
  2. BStandard precautions only, with the lesions covered
  3. CDroplet precautions until the pain settles
  4. DAirborne and contact precautions until all lesions are crusted
5.实验室检查值与电解质中等

In countries that screen all pregnant women (such as the US), a vaginal-rectal swab is taken at about 36–37 weeks. Which organism is it screening for?

  1. ACandida albicans
  2. BStaphylococcus aureus
  3. CHepatitis B virus
  4. DGroup B Streptococcus
6.实验室检查值与电解质困难

A patient with long-term heavy alcohol use is admitted with alcohol withdrawal. Which group of electrolyte problems is most common?

  1. AHigh sodium, high calcium and high glucose
  2. BLow chloride, high bicarbonate and high calcium
  3. CHigh magnesium, high phosphate and high potassium
  4. DLow magnesium, low phosphate and low potassium
7.临床护理中等

一名患者腹部僵硬如板，因活动会加重疼痛而一动不动地躺着。这提示什么？

  1. A尿路感染
  2. B消化不良
  3. C便秘
  4. D腹膜炎
8.临床护理困难

Which type of drug is commonly used to treat neuropathic pain?

  1. ASome anticonvulsants or antidepressants, such as gabapentin
  2. BProton pump inhibitors such as omeprazole
  3. CAntibiotics such as amoxicillin, given as a long course
  4. DAntihistamines such as cetirizine
9.内外科护理：心血管与呼吸中等

Why should a long-acting beta-2 agonist (LABA) never be used alone in asthma?

  1. AIt always causes immediate severe bronchospasm when used on its own
  2. BIt cannot be inhaled without a nebuliser
  3. CWithout an inhaled steroid, it is linked with severe and fatal attacks
  4. DIt works only when it is taken together with a course of antibiotics
10.内外科护理：心血管与呼吸困难

Which instruction from the registered nurse to a healthcare assistant (unlicensed assistive personnel) caring for a patient with COPD is most appropriate?

  1. A"Teach him how to use his new inhaler this afternoon after his rest."
  2. B"Turn his oxygen up to whatever he needs if he looks short of breath."
  3. C"Tell me straight away if his SpO₂ is under 88% or he is more breathless."
  4. D"Listen to his chest after lunch and let me know what you can hear."
11.内外科护理：神经、内分泌与肾脏中等

A patient with severe vomiting and diarrhoea takes ramipril, furosemide and metformin. Which advice is correct?

  1. AAdd ibuprofen to treat the abdominal cramps
  2. BKeep taking everything as normal and drink less
  3. CPause these medicines until eating and drinking again
  4. DDouble the furosemide to prevent fluid retention
12.内外科护理：神经、内分泌与肾脏困难

A patient with diabetes insipidus after head trauma needs hourly urine output measurement. Which task can be delegated to a trained healthcare assistant (nursing assistant)?

  1. AAssessing the patient's level of consciousness
  2. BInterpreting the serum sodium results
  3. CMeasuring hourly urine and reporting results above a set amount
  4. DDeciding whether to give the next desmopressin dose
13.内外科护理：消化、围手术期与肿瘤中等

How does sucralfate help a peptic ulcer heal?

  1. AIt blocks histamine receptors on parietal cells
  2. BIt speeds up emptying of the stomach
  3. CIt forms a protective coating over the ulcer base
  4. DIt kills H. pylori in the stomach lining
14.内外科护理：消化、围手术期与肿瘤困难

After a coughing fit, the external mark on a patient's nasogastric tube has moved 10 cm. Feed is due. What should the nurse do?

  1. APush the tube back to the original mark and start the feed
  2. BDo not use the tube until its position is confirmed by policy
  3. CStart the feed at a slow rate and watch for coughing
  4. DGive the medicines only and save the feed for later

3溶液

1.优先排序与委派

答案: C · Dark purple or black

为什么是这个答案

A healthy stoma is moist and pink to red, and early swelling or slight bleeding is common. A dark purple or black stoma suggests poor blood supply (ischemia) and needs urgent review.

答案

C · Dark purple or black
2.优先排序与委派

答案: D · Loosen the restraint and assess the circulation

为什么是这个答案

Pale, cool fingers with tingling suggest that the restraint is too tight and blood flow is reduced. The nurse releases it at once, assesses the hand and reviews whether the restraint is still needed.

答案

D · Loosen the restraint and assess the circulation
3.感染控制与患者安全

答案: A · Contact precautions in addition to standard precautions

为什么是这个答案

Hepatitis A spreads through fecal contamination. For a patient who is incontinent or in diapers, contact precautions are added to standard precautions to prevent spread on hands and surfaces.

答案

A · Contact precautions in addition to standard precautions
4.感染控制与患者安全

答案: D · Airborne and contact precautions until all lesions are crusted

为什么是这个答案

Lesions over several areas on both sides mean disseminated zoster, which can spread through the air like chickenpox. Airborne and contact precautions are used until all lesions are dry and crusted. Localized zoster in an immunocompromised patient also needs airborne and contact precautions, but only until dissemination is ruled out.

答案

D · Airborne and contact precautions until all lesions are crusted
5.实验室检查值与电解质

答案: D · Group B Streptococcus

为什么是这个答案

Group B streptococci can colonize the vagina and rectum and can cause severe infection in newborns. Women who test positive receive IV antibiotics during labor to reduce transmission to the baby. The UK does not screen all women routinely; it uses a risk-based approach instead.核对依据: Group B streptococcal septicemia of the newborn · MedlinePlus (NIH) (2024)

答案

D · Group B Streptococcus
6.实验室检查值与电解质

答案: D · Low magnesium, low phosphate and low potassium

为什么是这个答案

Poor diet, vomiting, diarrhea and alcohol's effect on the kidneys commonly cause low magnesium, phosphate and potassium. These worsen arrhythmia and seizure risk, so they are checked and replaced, together with thiamine.

答案

D · Low magnesium, low phosphate and low potassium
7.临床护理

答案: D · 腹膜炎

为什么是这个答案

腹膜炎（常由穿孔引起）会导致肌紧张、腹壁强直以及活动时疼痛加重。这是外科急症。

答案

D · 腹膜炎
8.临床护理

答案: A · Some anticonvulsants or antidepressants, such as gabapentin

为什么是这个答案

Neuropathic pain responds poorly to standard analgesics. Drugs that modify nerve signalling, such as gabapentinoids and some antidepressants, are used, with doses increased gradually.

答案

A · Some anticonvulsants or antidepressants, such as gabapentin
9.内外科护理：心血管与呼吸

答案: C · Without an inhaled steroid, it is linked with severe and fatal attacks

为什么是这个答案

LABA monotherapy in asthma is linked with severe attacks and asthma deaths because it relieves symptoms while airway inflammation continues. In asthma, LABAs are always given with an inhaled corticosteroid, often in one combination inhaler.

答案

C · Without an inhaled steroid, it is linked with severe and fatal attacks
10.内外科护理：心血管与呼吸

答案: C · "Tell me straight away if his SpO₂ is under 88% or he is more breathless."

为什么是这个答案

Delegated tasks should come with specific parameters for reporting. Changing oxygen therapy, chest assessment and patient teaching need a registered nurse's knowledge and judgement. Clear reporting instructions keep the patient safe.

答案

C · "Tell me straight away if his SpO₂ is under 88% or he is more breathless."
11.内外科护理：神经、内分泌与肾脏

答案: C · Pause these medicines until eating and drinking again

为什么是这个答案

During dehydrating illness, ACE inhibitors, diuretics and metformin can worsen AKI or its complications. Sick-day guidance usually advises pausing them until the person is eating and drinking normally, and NSAIDs are avoided.

答案

C · Pause these medicines until eating and drinking again
12.内外科护理：神经、内分泌与肾脏

答案: C · Measuring hourly urine and reporting results above a set amount

为什么是这个答案

Measuring and recording urine output with clear instructions on when to report is suitable for a trained assistant. Medication decisions, neurological assessment and interpreting results stay with the registered nurse.

答案

C · Measuring hourly urine and reporting results above a set amount
13.内外科护理：消化、围手术期与肿瘤

答案: C · It forms a protective coating over the ulcer base

为什么是这个答案

Sucralfate binds to the ulcer base and forms a barrier against acid and pepsin. It works best on an empty stomach and can reduce the absorption of other drugs, so doses are separated.

答案

C · It forms a protective coating over the ulcer base
14.内外科护理：消化、围手术期与肿瘤

答案: B · Do not use the tube until its position is confirmed by policy

为什么是这个答案

A change in external length means the tube may have moved. Pushing it back blindly is unsafe. It is not used until placement is confirmed by pH or X-ray, or it is replaced.

答案

B · Do not use the tube until its position is confirmed by policy

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