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 is admitted with diabetic ketoacidosis. Which prescribed treatment is usually started first?

  1. ASubcutaneous long-acting insulin only, given once
  2. BIV isotonic fluid such as 0.9% sodium chloride
  3. COral potassium tablets
  4. DA high-carbohydrate meal
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. ASeizure precautions and close neurological checks
  2. BEncouraging the patient to drink plenty of water
  3. CHelping the patient to walk in the corridor alone
  4. DTeaching the patient about a low-sodium diet at home
3.感染控制与患者安全中等

输液泵的药物库提示设定剂量超过安全上限。护士应怎么做？

  1. A首先重新核对医嘱、计算和泵的设置
  2. B为这次输注关闭药物库
  3. C继续输注，在本班结束时再检查泵
  4. D忽略该警报，因为泵的警报常常有误
4.感染控制与患者安全困难

A nurse notices that the pharmacy has sent the wrong dose and corrects it before giving it. Should the event be reported?

  1. ANo, because the patient was not harmed
  2. BYes, near misses are reported so system weaknesses can be fixed
  3. CNo, because reporting near misses only blames the pharmacy staff for nothing
  4. DOnly if the same error happens three times
5.实验室检查值与电解质中等

Which technique is recommended for a capillary blood glucose test on an adult's finger?

  1. APrick the center of the fingertip
  2. BPrick the side of the fingertip
  3. CSqueeze the finger very hard
  4. DUse the same finger every time
6.实验室检查值与电解质困难

A patient with acute kidney injury after severe dehydration has a rising creatinine. Which urine findings support a prerenal cause rather than acute tubular necrosis (ATN)?

  1. ARed cell casts with heavy protein loss in the urine
  2. BLow urine sodium and concentrated urine with a high specific gravity
  3. CHigh urine sodium and dilute urine with muddy brown granular casts
  4. DWhite cell casts with positive nitrites on the dipstick
7.临床护理中等

Under the Mental Capacity Act 2005 (England and Wales), which principle applies?

  1. AEveryone over 75 is assumed to lack capacity
  2. BA diagnosis of dementia means the person lacks capacity for all decisions
  3. CA person must be assumed to have capacity unless it is shown that they lack it
  4. DCapacity is decided by the next of kin, who must sign a form for every decision
8.临床护理困难

A patient's hypoglycaemia was caused by a sulfonylurea such as gliclazide or glipizide. Why might they need monitoring for longer than usual?

  1. ASulfonylureas only work at night
  2. BThe drug makes glucose tablets and drinks ineffective
  3. CSulfonylureas act for a long time, so hypoglycaemia can recur
  4. DThe drug causes rebound hyperglycaemia later the same day
9.内外科护理：心血管与呼吸中等

Why is aspirin chewed rather than swallowed whole in a suspected acute coronary syndrome?

  1. AChewing changes aspirin into an anticoagulant
  2. BChewing speeds absorption, giving a faster antiplatelet effect
  3. CWhole aspirin tablets cannot be absorbed at all from the gut
  4. DChewing stops the aspirin from irritating the lining of the stomach
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. ALie them down on the floor and start chest compressions immediately
  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. DSweep blindly in the mouth with a finger
11.内外科护理：神经、内分泌与肾脏中等

长期服用苯妥英的患者应被告知哪种副作用？

  1. A牙龈增生，因此良好的口腔卫生很重要
  2. B逐渐发生的永久性听力丧失
  3. C几乎所有患者都会头皮脱发
  4. D体重减轻和不耐热
12.内外科护理：神经、内分泌与肾脏困难

A patient has frothy urine and marked leg swelling. Serum albumin is 18 g/L (1.8 g/dL), and BP is normal. The urine shows heavy protein but little blood. What is most likely?

  1. ANephrotic syndrome
  2. BNephritic syndrome
  3. CA urethral stricture
  4. DAcute pyelonephritis
13.内外科护理：消化、围手术期与肿瘤中等

Which is a recognised risk of long-term proton pump inhibitor use?

  1. AHypomagnesaemia
  2. BHypernatraemia
  3. CHyperkalaemia
  4. DHypercalcaemia
14.内外科护理：消化、围手术期与肿瘤困难

一名回肠造口患者 6 小时没有排出物，伴绞痛、腹胀、恶心和造口肿胀。护士应怀疑什么？

  1. A新回肠造口的正常安静期
  2. B造口堵塞，常由食物引起，需要评估
  3. C回肠造口排出量过大引起的脱水
  4. D造口周围轻微皮疹

3溶液

1.优先排序与委派

答案: B · IV isotonic fluid such as 0.9% sodium chloride

为什么是这个答案

Patients with DKA are severely dehydrated, so IV isotonic fluid is started first. IV insulin follows, with close monitoring of potassium, which can fall quickly.

答案

B · IV isotonic fluid such as 0.9% sodium chloride
2.优先排序与委派

答案: A · 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

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

答案: A · 首先重新核对医嘱、计算和泵的设置

为什么是这个答案

智能输液泵的限值用于发现编程和计算错误。护士应先核对医嘱、浓度、剂量和速率，再决定是否确实适合忽略警报。

答案

A · 首先重新核对医嘱、计算和泵的设置
4.感染控制与患者安全

答案: B · Yes, near misses are reported so system weaknesses can be fixed

为什么是这个答案

Near misses show where errors can slip through and are reported in the same way as errors that reach the patient. Learning from them prevents future harm.

答案

B · Yes, near misses are reported so system weaknesses can be fixed
5.实验室检查值与电解质

答案: B · Prick the side of the fingertip

为什么是这个答案

The sides of the fingertips are less sensitive than the pads, so they are used for capillary sampling. Rotating sites reduces soreness, and hard squeezing can add tissue fluid that gives inaccurate results.

答案

B · Prick the side of the fingertip
6.实验室检查值与电解质

答案: B · Low urine sodium and concentrated urine with a high specific gravity

为什么是这个答案

In prerenal AKI the tubules are intact, so they keep sodium and water, giving a low urine sodium and concentrated urine. In ATN the damaged tubules cannot do this, so urine sodium is high, the urine is dilute and muddy brown casts appear.核对依据: Urine specific gravity test · MedlinePlus (NIH) (2025)

答案

B · Low urine sodium and concentrated urine with a high specific gravity
7.临床护理

答案: C · A person must be assumed to have capacity unless it is shown that they lack it

为什么是这个答案

The Act begins by presuming capacity. Capacity is decision-specific and time-specific, and people must be given all practicable help to make their own decision.

答案

C · A person must be assumed to have capacity unless it is shown that they lack it
8.临床护理

答案: C · Sulfonylureas act for a long time, so hypoglycaemia can recur

为什么是这个答案

Sulfonylureas stimulate insulin release and have a long duration of action. Hypoglycaemia can be prolonged or recur, so glucose is monitored closely after treatment.

答案

C · Sulfonylureas act for a long time, so hypoglycaemia can recur
9.内外科护理：心血管与呼吸

答案: B · Chewing speeds absorption, giving a faster antiplatelet effect

为什么是这个答案

Aspirin irreversibly inhibits platelet cyclo-oxygenase, reducing thromboxane A2 and platelet aggregation. Chewing a non-enteric-coated tablet speeds absorption. It reduces mortality in acute coronary syndromes and is given unless there is a true allergy.

答案

B · Chewing speeds absorption, giving a faster antiplatelet effect
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: A · 牙龈增生，因此良好的口腔卫生很重要

为什么是这个答案

苯妥英常引起牙龈增生，还可引起多毛、面部特征粗糙，高浓度时出现共济失调、眼球震颤和嗜睡。良好的牙齿护理可减少牙龈问题。该药治疗窗窄，因此要监测血药浓度。

答案

A · 牙龈增生，因此良好的口腔卫生很重要
12.内外科护理：神经、内分泌与肾脏

答案: A · Nephrotic syndrome

为什么是这个答案

Heavy proteinuria, very low albumin and oedema point to nephrotic syndrome. Nephritic syndrome is mainly haematuria with hypertension and reduced urine output. The cause is investigated, often with a biopsy.

答案

A · Nephrotic syndrome
13.内外科护理：消化、围手术期与肿瘤

答案: A · Hypomagnesaemia

为什么是这个答案

Long-term PPIs are linked with low magnesium, C. difficile infection, fractures and B12 deficiency. The need for continuing treatment should be reviewed regularly.

答案

A · Hypomagnesaemia
14.内外科护理：消化、围手术期与肿瘤

答案: B · 造口堵塞，常由食物引起，需要评估

为什么是这个答案

无排出物伴绞痛、腹胀、恶心或呕吐以及造口肿胀，提示梗阻，常由含纤维的食物引起。患者需要评估；可给予液体并寻求专科建议。未经医疗建议不得使用泻药。

答案

B · 造口堵塞，常由食物引起，需要评估

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