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

Which action helps prevent a catheter-associated urinary tract infection?

  1. ARaising the drainage bag above the bladder when walking
  2. BDisconnecting the bag every shift to empty it
  3. CLeaving the catheter in place longer than needed
  4. DKeeping the drainage bag below the level of the bladder
2.优先排序与委派困难

护士应对哪位患者的计划出院提出质疑？

  1. A石膏稳定、能用拐杖安全行走的患者
  2. B疝修补术后，已排尿并进食的患者
  3. C肺炎患者，口服抗生素后已 48 小时无发热
  4. D术后两天，新出现心率 112 次/分、体温 38.4 °C 的患者
3.感染控制与患者安全中等

Before helping a patient from bed into a wheelchair, what should the nurse do with the wheelchair?

  1. ALeave the brakes off so the chair can move along with the patient during the pivot
  2. BPlace it on the patient’s weaker side so that side is supported
  3. CPlace it at the foot of the bed, facing away
  4. DLock the brakes and place it close to the bed on the patient’s stronger side
4.感染控制与患者安全困难

一名患者因急性腹泻入院，怀疑为艰难梭菌（C. difficile）感染。检测结果尚未出来。接触传播预防应何时开始？

  1. A仅在检测结果呈阳性时
  2. B立即开始，无需等待检测结果
  3. C腹泻三天之后
  4. D仅在患者发热时
5.实验室检查值与电解质中等

Two sets of blood cultures are ordered for a patient with suspected sepsis. How are they best collected?

  1. ABoth from the same site, one minute apart, to save time for the patient
  2. BFrom two separate venipuncture sites, using strict aseptic technique
  3. CFrom the existing IV line while the infusion continues to run
  4. DAfter the first antibiotic dose, so the infusion is not delayed
6.实验室检查值与电解质困难

The nurse teaches a patient with thrombocytopenia (platelets 25 × 10³/µL) about home safety. Which statement shows a need for further teaching?

  1. A"I'll blow my nose gently, not forcefully"
  2. B"I'll use a soft-bristled toothbrush"
  3. C"I'll use an electric razor to shave"
  4. D"I'll take aspirin if I get a headache"
7.临床护理中等

A patient is receiving enteral feeding through a nasogastric tube. How should they be positioned during feeding?

  1. ALying completely flat
  2. BWith the head of the bed raised to at least 30 degrees
  3. CLying on the left side with the head down to help the feed drain
  4. DIn any position, as long as the feed runs slowly
8.临床护理困难

一名头部外伤患者出现血压升高、心率减慢和呼吸不规则。这提示：

  1. A颅内压增高（库欣三联征）
  2. B隐匿性内出血引起的低血容量性休克
  3. C惊恐发作
  4. D脓毒症
9.内外科护理：心血管与呼吸中等

How does varenicline help people stop smoking?

  1. AIt speeds the clearance of nicotine by the liver
  2. BIt replaces nicotine through the skin, like a nicotine patch
  3. CIt makes cigarettes taste of metal so smoking feels unpleasant
  4. DIt partly stimulates and partly blocks nicotine receptors
10.内外科护理：心血管与呼吸困难

A patient receiving weeks of IV antibiotics through a PICC line in the left arm develops swelling and aching of that arm and neck veins that look fuller on the left. What should the nurse suspect?

  1. AAn expected effect of the antibiotic
  2. BLymphoedema from lying in bed
  3. CA catheter-related deep vein thrombosis
  4. DA local skin allergy to the dressing
11.内外科护理：神经、内分泌与肾脏中等

A patient with Conn's syndrome starts spironolactone. Which blood test should the nurse watch most closely?

  1. AAmylase
  2. BCalcium
  3. CGlucose
  4. DPotassium
12.内外科护理：神经、内分泌与肾脏困难

A patient with trigeminal neuralgia has lost weight and has poor oral hygiene. Which plan is most appropriate?

  1. AAdvise very hot drinks to relax the facial nerves
  2. BOffer soft, lukewarm food and advise chewing on the unaffected side
  3. CEncourage hard, crunchy foods to strengthen the jaw muscles
  4. DTell the patient to stop brushing their teeth completely
13.内外科护理：消化、围手术期与肿瘤中等

Which lung problem is a known toxicity of bleomycin?

  1. ALung cancer within weeks
  2. BPneumothorax from coughing
  3. CAsthma from pollen
  4. DPulmonary fibrosis
14.内外科护理：消化、围手术期与肿瘤困难

上腹部手术后第 2 天，一名患者体温 37.8 °C，未吸氧时 SpO₂ 93%，双肺底呼吸音减弱。由于疼痛，他们没有使用激励式肺量计。最恰当的护理计划是什么？

  1. A以 15 L/min 给氧，让患者安静休息
  2. B停用所有镇痛药，使患者能更用力地咳嗽
  3. C更好地控制疼痛、坐起、深呼吸、活动并上报
  4. D让患者卧床并限制活动，直到发热消退

3溶液

1.优先排序与委派

答案: D · Keeping the drainage bag below the level of the bladder

为什么是这个答案

Keeping the bag below the bladder prevents backflow, and the closed system is not broken. Catheters are removed as soon as they are no longer needed.

答案

D · Keeping the drainage bag below the level of the bladder
2.优先排序与委派

答案: D · 术后两天，新出现心率 112 次/分、体温 38.4 °C 的患者

为什么是这个答案

术后新出现发热和心动过速可能提示感染或其他并发症，因此护士在出院前应评估并提出该问题。其他患者是稳定的，达到了预期目标。

答案

D · 术后两天，新出现心率 112 次/分、体温 38.4 °C 的患者
3.感染控制与患者安全

答案: D · Lock the brakes and place it close to the bed on the patient’s stronger side

为什么是这个答案

Locked brakes stop the chair rolling away during the transfer. Placing it close to the bed on the stronger side lets the patient lead with their strong leg.

答案

D · Lock the brakes and place it close to the bed on the patient’s stronger side
4.感染控制与患者安全

答案: B · 立即开始，无需等待检测结果

为什么是这个答案

一旦怀疑就应开始采取预防措施，因为在检测结果待出期间患者就可能传播芽孢。患者应安置在单间并采取接触传播预防，同时使用肥皂和水洗手。

答案

B · 立即开始，无需等待检测结果
5.实验室检查值与电解质

答案: B · From two separate venipuncture sites, using strict aseptic technique

为什么是这个答案

Taking cultures from two separate sites helps distinguish true bacteremia (growth in both sets) from skin contamination (growth in only one). The skin is cleaned carefully, the bottle tops are disinfected, and cultures are taken before antibiotics.

答案

B · From two separate venipuncture sites, using strict aseptic technique
6.实验室检查值与电解质

答案: D · "I'll take aspirin if I get a headache"

为什么是这个答案

Aspirin irreversibly inhibits platelet function and raises the bleeding risk further in thrombocytopenia, so it and other NSAIDs are avoided unless prescribed. An electric razor, gentle nose blowing and a soft toothbrush reduce minor bleeding.核对依据: Bleeding and Bruising (Thrombocytopenia) and Cancer Treatment · National Cancer Institute (NIH) (2022); Aspirin · MedlinePlus (NIH) (2025)

答案

D · "I'll take aspirin if I get a headache"
7.临床护理

答案: B · With the head of the bed raised to at least 30 degrees

为什么是这个答案

Keeping the head raised to at least 30–45° during feeding and for a period afterwards lowers the risk of aspiration pneumonia.

答案

B · With the head of the bed raised to at least 30 degrees
8.临床护理

答案: A · 颅内压增高（库欣三联征）

为什么是这个答案

库欣三联征（高血压伴脉压增大、心动过缓和呼吸不规则）是颅内压增高的晚期征象，需要紧急处理。

答案

A · 颅内压增高（库欣三联征）
9.内外科护理：心血管与呼吸

答案: D · It partly stimulates and partly blocks nicotine receptors

为什么是这个答案

Varenicline is a partial agonist at nicotinic acetylcholine receptors. It reduces cravings and withdrawal and makes smoking less rewarding. Nausea is common, and patients are asked to report mood changes.

答案

D · It partly stimulates and partly blocks nicotine receptors
10.内外科护理：心血管与呼吸

答案: C · A catheter-related deep vein thrombosis

为什么是这个答案

Upper-limb DVT is a recognised complication of PICCs and other central lines. Arm swelling, pain and distended veins should be reported, and an ultrasound arranged. The line is not flushed forcefully, and treatment usually involves anticoagulation.

答案

C · A catheter-related deep vein thrombosis
11.内外科护理：神经、内分泌与肾脏

答案: D · Potassium

为什么是这个答案

Spironolactone is an aldosterone antagonist. It retains potassium, so hyperkalaemia can develop, especially with kidney disease or ACE inhibitors. Breast enlargement is another known side effect.

答案

D · Potassium
12.内外科护理：神经、内分泌与肾脏

答案: B · Offer soft, lukewarm food and advise chewing on the unaffected side

为什么是这个答案

Patients may avoid eating and brushing their teeth because these trigger attacks. Soft, lukewarm food, chewing on the unaffected side, gentle oral care and effective drug treatment help maintain nutrition and hygiene.

答案

B · Offer soft, lukewarm food and advise chewing on the unaffected side
13.内外科护理：消化、围手术期与肿瘤

答案: D · Pulmonary fibrosis

为什么是这个答案

Bleomycin can cause pneumonitis and pulmonary fibrosis, especially at higher cumulative doses, in older patients and with high oxygen concentrations. Breathlessness or a new cough must be reported.

答案

D · Pulmonary fibrosis
14.内外科护理：消化、围手术期与肿瘤

答案: C · 更好地控制疼痛、坐起、深呼吸、活动并上报

为什么是这个答案

上腹部手术后，当疼痛限制深呼吸时，肺底部肺不张很常见。良好的镇痛、直立体位、深呼吸练习、激励式肺量计、支托下咳嗽和早期活动可使肺重新扩张。应报告这些发现，因为它们可能发展为肺炎；需要时给氧至目标值。

答案

C · 更好地控制疼痛、坐起、深呼吸、活动并上报

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