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 coughs hard after abdominal surgery, and loops of bowel appear through the opened wound. What does the nurse do first?

  1. ALeave the wound uncovered so the surgeon can see it on arrival
  2. BHelp the patient walk to the toilet to relieve abdominal pressure
  3. CCover the wound with sterile dressings moistened with saline
  4. DPush the bowel gently back into the abdomen with a gloved hand
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. ATighten the restraint so the patient moves less
  2. BRaise the arm on a pillow and check again in two hours
  3. CDocument the finding and continue with the medication round
  4. DLoosen the restraint and assess the circulation
3.感染控制与患者安全中等

A patient has leftover opioid tablets after surgery. Which advice about disposal is best?

  1. AGive them to a friend or relative who has back pain
  2. BLeave them in the bathroom cabinet indefinitely
  3. CReturn them to a pharmacy or an approved take-back site
  4. DKeep them in an unlocked drawer at home in case of future pain
4.感染控制与患者安全困难

A patient’s allergy band says “penicillin”, and an order has been written for amoxicillin. What should the nurse do?

  1. AAsk the patient whether they would like to take it anyway
  2. BGive an antihistamine first and then the drug
  3. CHold the drug and contact the prescriber
  4. DGive the drug and watch the patient closely
5.实验室检查值与电解质中等

A patient has taken a proton pump inhibitor (such as omeprazole) for many years and now has muscle cramps and tremor. Which electrolyte is most likely to be low?

  1. ASodium
  2. BPhosphate
  3. CChloride
  4. DMagnesium
6.实验室检查值与电解质困难

A patient has fatigue, weight loss, darkening of the skin and low blood pressure. Results: sodium 130 mEq/L, potassium 5.6 mEq/L. Which test pattern would confirm primary adrenal insufficiency (Addison disease)?

  1. AHigh cortisol with a low ACTH
  2. BHigh cortisol with a high ACTH
  3. CLow cortisol with a high ACTH
  4. DLow cortisol with a low ACTH
7.临床护理中等

Compared with a colostomy, a patient with an ileostomy is at greater risk of:

  1. AUrinary retention
  2. BDehydration and electrolyte loss from liquid output
  3. CHard stools, straining and constipation from slow transit
  4. DLow blood glucose after meals
8.临床护理困难

A patient starting a DOAC is taught about missed doses. Which statement shows a need for further teaching?

  1. A"I will report any blood in my urine."
  2. B"I will take it at the same time each day."
  3. C"If I forget a dose, I'll take two the next day to catch up."
  4. D"I will tell other doctors and my dentist I take an anticoagulant."
9.内外科护理：心血管与呼吸中等

为什么鼓励重度 COPD 患者少量多餐？

  1. A胃饱胀会限制膈肌活动，而且进食本身就很累
  2. B少量进餐可减少使用吸入器的次数
  3. C频繁进餐可直接预防胸部感染
  4. D大餐会使气道永久性变窄
10.内外科护理：心血管与呼吸困难

早晨给地高辛之前，患者的心尖脉搏为 54 次/分，并感到恶心。护士应怎么做？

  1. A给药并给止吐药，明天再复查脉搏
  2. B给半量，一小时后复查脉搏
  3. C暂停给药并上报，因为可能发生中毒
  4. D给药，因为只有桡动脉脉搏才算数
11.内外科护理：神经、内分泌与肾脏中等

An 82-year-old taking apixaban fell three weeks ago. Since then their family has noticed increasing confusion and headaches. Which condition is most likely?

  1. AChronic subdural haematoma
  2. BSubarachnoid haemorrhage from an aneurysm
  3. CAcute extradural haematoma
  4. DNormal ageing with mild memory loss
12.内外科护理：神经、内分泌与肾脏困难

手术后，一名患者尿量连续 3 小时为 15 mL/h，脉搏 110 次/分，血压 96/58 mmHg，黏膜干燥。尿量少最可能的原因是什么？

  1. A麻醉后的尿崩症
  2. B低血容量引起的肾前性 AKI
  3. C手术引起的 SIADH
  4. D静脉输液引起的液体过多
13.内外科护理：消化、围手术期与肿瘤中等

伤口愈合的哪个阶段涉及肉芽组织和新生血管的形成？

  1. A成熟期
  2. B炎症期
  3. C止血（凝血）期
  4. D增殖期
14.内外科护理：消化、围手术期与肿瘤困难

A nurse finds a dislodged sealed radiation source in the bed of a patient receiving brachytherapy. What should the nurse do?

  1. APick it up with gloved hands and put it in the nearest sharps bin quickly
  2. BUse long-handled forceps to put it in the lead container; report it
  3. CThrow it in the clinical waste bag
  4. DLeave it in the bed until the end of the shift

3溶液

1.优先排序与委派

答案: C · Cover the wound with sterile dressings moistened with saline

为什么是这个答案

Evisceration is a surgical emergency. The nurse covers the organs with sterile saline-moistened dressings, stays with the patient, positions them to reduce strain and calls the surgeon at once.

答案

C · Cover the wound with sterile dressings moistened with saline
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: C · Return them to a pharmacy or an approved take-back site

为什么是这个答案

Returning unused opioids to a pharmacy or an approved take-back site is the preferred way to dispose of them. Leftover opioids at home can be misused or taken by children or pets.

答案

C · Return them to a pharmacy or an approved take-back site
4.感染控制与患者安全

答案: C · Hold the drug and contact the prescriber

为什么是这个答案

Amoxicillin is a penicillin, so it could cause a serious allergic reaction. The nurse holds the drug, clarifies the allergy and contacts the prescriber for a safe alternative.

答案

C · Hold the drug and contact the prescriber
6.实验室检查值与电解质

答案: C · Low cortisol with a high ACTH

为什么是这个答案

In primary adrenal insufficiency the adrenal glands fail, so cortisol is low and the pituitary responds with high ACTH, which also darkens the skin. Low cortisol with low ACTH suggests a pituitary cause. An ACTH stimulation test confirms the diagnosis.核对依据: Adrenocorticotropic Hormone (ACTH) · MedlinePlus (NIH) (2023); Cortisol Test · MedlinePlus (NIH) (2024)

答案

C · Low cortisol with a high ACTH
7.临床护理

答案: B · Dehydration and electrolyte loss from liquid output

为什么是这个答案

Ileostomy output is liquid because it bypasses the colon, which normally absorbs water and salts. Patients must drink enough and watch for signs of dehydration, especially in hot weather or illness.

答案

B · Dehydration and electrolyte loss from liquid output
8.临床护理

答案: C · "If I forget a dose, I'll take two the next day to catch up."

为什么是这个答案

Doubling up on an anticoagulant increases the bleeding risk. Patients follow the specific missed-dose advice for their drug and never take a double dose.

答案

C · "If I forget a dose, I'll take two the next day to catch up."
9.内外科护理：心血管与呼吸

答案: A · 胃饱胀会限制膈肌活动，而且进食本身就很累

为什么是这个答案

许多重度 COPD 患者体重下降，因为呼吸消耗大量能量，而大餐会引起腹胀和呼吸困难。少量、营养密度高的餐食有助于维持体重和肌力。

答案

A · 胃饱胀会限制膈肌活动，而且进食本身就很累
10.内外科护理：心血管与呼吸

答案: C · 暂停给药并上报，因为可能发生中毒

为什么是这个答案

常见规则是：如果心尖脉搏低于 60 次/分（或低于设定的参数），或出现恶心、呕吐、视觉障碍或新的心律失常等中毒表现，则暂停地高辛并通知开处方者。通常还需检查地高辛浓度、心电图、钾和肾功能。护士不得自行更改剂量。

答案

C · 暂停给药并上报，因为可能发生中毒
11.内外科护理：神经、内分泌与肾脏

答案: A · Chronic subdural haematoma

为什么是这个答案

Older people have brain atrophy that stretches the bridging veins, and anticoagulants increase bleeding. A slow venous bleed can cause gradual confusion, headache or weakness over weeks. A CT scan is needed.

答案

A · Chronic subdural haematoma
12.内外科护理：神经、内分泌与肾脏

答案: B · 低血容量引起的肾前性 AKI

为什么是这个答案

心动过速、低血压和黏膜干燥提示低血容量，使肾灌注减少。护士应检查导尿管是否通畅并上报；团队通常会开具补液试验并寻找出血或大量丢失等原因。

答案

B · 低血容量引起的肾前性 AKI
13.内外科护理：消化、围手术期与肿瘤

答案: D · 增殖期

为什么是这个答案

愈合有四个相互重叠的阶段：止血、炎症、增殖（肉芽组织、血管生成和上皮化）和成熟（胶原重塑，可持续一年或更久）。

答案

D · 增殖期
14.内外科护理：消化、围手术期与肿瘤

答案: B · Use long-handled forceps to put it in the lead container; report it

为什么是这个答案

A dislodged source is picked up with long-handled forceps and placed in the shielded container kept in the room. The radiation safety officer and team are informed, following local policy.

答案

B · Use long-handled forceps to put it in the lead container; report it

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