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 drowsy patient who has just returned from surgery starts to vomit. What should the nurse do first?

  1. ARaise the legs above the heart
  2. BGive an oral anti-sickness tablet
  3. CTurn the patient onto their side
  4. DGive a drink of water
2.优先排序与委派困难

交班后，护士应首先评估哪位患者？

  1. A胆囊手术后第 2 天：疼痛 6/10，下一次镇痛药 30 分钟后到期
  2. B2 型糖尿病：午餐前血糖 210 mg/dL（11.7 mmol/L），无症状
  3. CCOPD，吸氧 2 L/min：SpO₂ 90%，呼吸频率 22 次/分，处于平时的基线
  4. D经股动脉心导管术后 1 小时：新出现背痛，脉搏 118 次/分，血压 92/58 mmHg
3.感染控制与患者安全中等

How should the urethral meatus be cared for in a patient with an indwelling urinary catheter?

  1. AWith daily bladder irrigation using an antibiotic solution through the catheter
  2. BWith routine hygiene, using soap and water during daily washing
  3. CWith antiseptic cream applied to the meatus every shift
  4. DBy sliding the catheter in and out a little to clean it
4.感染控制与患者安全困难

A nurse calls a provider using SBAR about a patient with falling blood pressure. Which statement is the “Recommendation”?

  1. A“He is 72 and had a bowel resection yesterday.”
  2. B“I am calling about Mr. Jansen in room 12, who is hypotensive.”
  3. C“His blood pressure has fallen from 130/80 to 88/50 over the last two hours.”
  4. D“I think he needs to be assessed now. Can you come within the next 15 minutes?”
5.实验室检查值与电解质中等

After surgery for colon cancer, a patient's CEA had fallen to normal, but it has been rising over the last two checks. What does this most likely suggest?

  1. AA sure sign that the cancer has been fully cured
  2. BA normal change after surgery that needs no follow-up
  3. CPossible recurrence that needs further assessment
  4. DA sign of iron deficiency from the earlier bleeding
6.实验室检查值与电解质困难

A patient on IV gentamicin has a trough level above the target, and the creatinine has risen since yesterday. The next dose is due. What is the best action?

  1. AGive half of the dose and document the reason for it
  2. BGive the dose with extra oral fluids to protect the kidneys
  3. CGive the dose now and recheck the levels next week
  4. DHold the dose and report the results to the prescriber
7.临床护理中等

一名开始服用 ACE 抑制剂的患者出现持续性干咳。可能的原因是什么？

  1. AACE 抑制剂的一种公认副作用
  2. B肺栓塞
  3. C对最近所给青霉素的过敏反应
  4. Dβ 受体阻滞剂引起的哮喘
8.临床护理困难

The fluid in an underwater seal chest drain has stopped swinging with breathing. What could this mean?

  1. AThe water seal has been set up correctly for the first time
  2. BThe drain is working perfectly and needs no checks
  3. CThe patient's breathing has become normal and the drain can be pulled out by the nurse
  4. DThe tube may be kinked or blocked, or the lung may have fully re-expanded
9.内外科护理：心血管与呼吸中等

A pulse oximeter on a patient's finger gives an unreliable, flickering reading. Which factor is the most likely cause?

  1. ACold hands with poor peripheral circulation
  2. BThe patient having eaten recently
  3. CA regular heart rate of 75 beats per minute
  4. DThe patient sitting upright in a chair
10.内外科护理：心血管与呼吸困难

Twelve hours after a coronary stent, a patient has sudden severe chest pain again with new ST elevation in the same leads. What is the most likely cause?

  1. AIndigestion from the hospital meal
  2. BNormal pain from the procedure site
  3. CPericarditis from the catheter
  4. DAcute stent thrombosis
11.内外科护理：神经、内分泌与肾脏中等

Which group of problems is typical of primary hyperparathyroidism?

  1. AMuscle cramps, tingling lips and seizures
  2. BHair loss, weight gain and feeling cold
  3. CKidney stones, bone pain, abdominal pain and low mood
  4. DHeat intolerance, tremor, weight loss and diarrhoea
12.内外科护理：神经、内分泌与肾脏困难

A 66-year-old smoker has had two episodes of painless red urine. Urine cultures are negative. Which plan is most appropriate?

  1. AAnother course of antibiotics for a UTI
  2. BReassure him, because the blood has stopped
  3. CUrgent referral for cystoscopy and imaging
  4. DAdvise more fluids and review in a year
13.内外科护理：消化、围手术期与肿瘤中等

什么是肿瘤溶解综合征？

  1. A最近接受放疗区域的皮肤反应
  2. B压迫神经的缓慢生长的肿瘤
  3. C对化疗输注的过敏反应
  4. D癌细胞迅速分解引起的代谢急症
14.内外科护理：消化、围手术期与肿瘤困难

A patient on modified-release morphine for cancer pain has needed four breakthrough doses every day for several days. What should the nurse do?

  1. AStop the breakthrough doses to reduce opioid use
  2. BTell the patient to put up with the pain between doses
  3. CReport it, as the regular background dose may need review
  4. DGive all breakthrough doses at the same time

3溶液

1.优先排序与委派

答案: C · Turn the patient onto their side

为什么是这个答案

A drowsy patient who vomits can aspirate. Turning them to the side lets vomit drain from the mouth; suction and a prescribed antiemetic follow.

答案

C · Turn the patient onto their side
2.优先排序与委派

答案: D · 经股动脉心导管术后 1 小时：新出现背痛，脉搏 118 次/分，血压 92/58 mmHg

为什么是这个答案

股动脉穿刺后出现背痛、心动过速和低血压，提示腹膜后出血，这种出血可能隐匿而致命。COPD 患者处于基线，疼痛是预期的且正在处理，血糖偏高但不是急症。

答案

D · 经股动脉心导管术后 1 小时：新出现背痛，脉搏 118 次/分，血压 92/58 mmHg
3.感染控制与患者安全

答案: B · With routine hygiene, using soap and water during daily washing

为什么是这个答案

Routine perineal hygiene with soap and water is recommended. Antiseptic creams and routine irrigation do not reduce infection, and moving the catheter in and out carries organisms into the bladder.

答案

B · With routine hygiene, using soap and water during daily washing
4.感染控制与患者安全

答案: D · “I think he needs to be assessed now. Can you come within the next 15 minutes?”

为什么是这个答案

In SBAR, the situation names the problem, the background gives the history, the assessment shares the nurse’s findings and judgement, and the recommendation states a clear request with a time frame.

答案

D · “I think he needs to be assessed now. Can you come within the next 15 minutes?”
5.实验室检查值与电解质

答案: C · Possible recurrence that needs further assessment

为什么是这个答案

CEA is not specific enough for screening, but a rising level after successful treatment can signal recurrence, so imaging and further assessment are usually arranged. Smoking and some benign conditions can also raise CEA.核对依据: CEA Test · MedlinePlus (NIH) (2026)

答案

C · Possible recurrence that needs further assessment
6.实验室检查值与电解质

答案: D · Hold the dose and report the results to the prescriber

为什么是这个答案

A high aminoglycoside trough with rising creatinine means the drug is accumulating, which increases the risk of kidney damage and hearing loss. The nurse holds the dose, reports to the prescriber and asks about hearing changes and tinnitus. Only the prescriber or pharmacist changes the regimen.核对依据: Gentamicin sulfate injection - Boxed Warning (US prescribing information) · Pfizer Medical Information (FDA label)

答案

D · Hold the dose and report the results to the prescriber
7.临床护理

答案: A · ACE 抑制剂的一种公认副作用

为什么是这个答案

干咳是雷米普利等 ACE 抑制剂的常见副作用。通常改用血管紧张素 II 受体阻滞剂。

答案

A · ACE 抑制剂的一种公认副作用
8.临床护理

答案: D · The tube may be kinked or blocked, or the lung may have fully re-expanded

为什么是这个答案

Loss of swing can mean a kinked, clamped or blocked tube, or re-expansion of the lung. The nurse checks the tubing and the patient and reports the finding.

答案

D · The tube may be kinked or blocked, or the lung may have fully re-expanded
9.内外科护理：心血管与呼吸

答案: A · Cold hands with poor peripheral circulation

为什么是这个答案

Poor perfusion (cold, shock, vasoconstriction), movement, dark nail varnish or bright ambient light can make readings unreliable. The nurse checks the waveform, warms the hand or uses an ear probe, and compares the reading with the clinical picture.

答案

A · Cold hands with poor peripheral circulation
10.内外科护理：心血管与呼吸

答案: D · Acute stent thrombosis

为什么是这个答案

Acute stent thrombosis presents with recurrent ischaemic pain and ST elevation, and needs emergency return to the catheter laboratory. Missed antiplatelet doses are a major risk factor, which is why dual antiplatelet adherence is emphasised.

答案

D · Acute stent thrombosis
11.内外科护理：神经、内分泌与肾脏

答案: C · Kidney stones, bone pain, abdominal pain and low mood

为什么是这个答案

High PTH raises calcium, which can cause kidney stones, bone loss and pain, constipation and abdominal pain, and low mood or confusion ("stones, bones, groans and moans"). Many cases are found on routine blood tests.

答案

C · Kidney stones, bone pain, abdominal pain and low mood
12.内外科护理：神经、内分泌与肾脏

答案: C · Urgent referral for cystoscopy and imaging

为什么是这个答案

Painless visible haematuria in an older smoker, with no infection, must be investigated urgently for bladder or kidney cancer. Intermittent bleeding does not mean the cause has gone.

答案

C · Urgent referral for cystoscopy and imaging
13.内外科护理：消化、围手术期与肿瘤

答案: D · 癌细胞迅速分解引起的代谢急症

为什么是这个答案

肿瘤细胞迅速死亡（通常在急性白血病或高级别淋巴瘤等快速生长的癌症开始治疗后）会释放钾、磷酸盐和核酸（转化为尿酸）。这可引起 AKI 和心律失常。

答案

D · 癌细胞迅速分解引起的代谢急症
14.内外科护理：消化、围手术期与肿瘤

答案: C · Report it, as the regular background dose may need review

为什么是这个答案

Regular need for breakthrough doses usually means the background analgesia is inadequate. The prescriber reviews and may adjust the regular dose, while side effects such as sedation are monitored.

答案

C · Report it, as the regular background dose may need review

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