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

一名稳定的成人腹痛，生命体征正常。他们将需要血液检查和 CT 扫描。哪个 ESI 级别合适？

  1. A4 级
  2. B3 级
  3. C1 级
  4. D5 级
2.优先排序与委派困难

A medical-unit nurse is floated to intensive care and given a patient on a ventilator, which the nurse has never managed. What is the best response?

  1. ARefuse to work and go home, because the assignment is unsafe
  2. BAccept the full assignment without comment to avoid conflict
  3. CTell the charge nurse about the gap, accept tasks within competence and ask for support
  4. DLeave the intensive care unit and go back to the medical unit without telling anyone
3.感染控制与患者安全中等

“Tall Man”大写字母标注法（如 hydrOXYzine 和 hydrALAZINE）的目的是什么？

  1. A使外观相似的药名更容易区分
  2. B表示商品名
  3. C表示药物的规格
  4. D表明两种药物中哪一种是高警示药物
4.感染控制与患者安全困难

A nurse cannot find a confused patient who was in their room 15 minutes ago. What should the nurse do first?

  1. AWait an hour in case the patient comes back
  2. BDocument the absence at the end of the shift
  3. CCall the family to ask whether the patient has gone home on their own
  4. DAlert staff and security at once, following the missing-patient procedure
5.实验室检查值与电解质中等

A healthy woman at 28 weeks of pregnancy has a mildly lower hemoglobin than before pregnancy, with a normal MCV and ferritin. What is the most likely explanation?

  1. APlasma volume rises more than red cell mass, diluting the blood
  2. BIron is being lost through the kidneys during the pregnancy
  3. CPregnancy hormones stop the bone marrow from making red cells
  4. DThe fetus is destroying the mother's red cells in the circulation
6.实验室检查值与电解质困难

A patient with severe sepsis is oozing blood from IV sites. Platelets 40 × 10³/µL, fibrinogen low, D-dimer very high, PT and aPTT both prolonged. Which condition fits best?

  1. ADisseminated intravascular coagulation (DIC)
  2. BImmune thrombocytopenic purpura (ITP)
  3. CHeparin-induced thrombocytopenia (HIT)
  4. DHemophilia A (factor VIII deficiency)
7.临床护理中等

A patient is receiving IV fluids for several days. Which monitoring is essential?

  1. AMonthly HbA1c
  2. BFluid balance, regular weights and urea, creatinine and electrolytes
  3. CWeekly temperature and a single blood glucose reading
  4. DPeak flow readings
8.临床护理困难

After a head injury, a patient has clear fluid leaking from the nose. What does this most likely suggest?

  1. AAcute sinusitis
  2. BA normal and harmless response to head trauma
  3. CAllergic rhinitis triggered by the hospital environment
  4. DA base-of-skull fracture with a cerebrospinal fluid leak
9.内外科护理：心血管与呼吸中等

A patient's capillary refill time at the fingertip is 4 seconds. What does this suggest?

  1. AReduced peripheral perfusion
  2. BNormal peripheral perfusion
  3. CA high haemoglobin level
  4. DAn unusually strong cardiac output
10.内外科护理：心血管与呼吸困难

A patient who has had a total laryngectomy becomes breathless and needs oxygen. How should it be given?

  1. AVia a standard face mask over the nose and mouth
  2. BVia a mask or humidified device over the neck stoma
  3. CVia nasal cannula at 2 L/min
  4. DVia a non-rebreather mask over the mouth only
11.内外科护理：神经、内分泌与肾脏中等

腹膜透析液使用前应如何加温？

  1. A在一盆热的自来水中
  2. B应直接从冰箱取出冷用
  3. C在微波炉中
  4. D在专用的干热加温器中
12.内外科护理：神经、内分泌与肾脏困难

一名老年 2 型糖尿病患者血糖 48 mmol/L，渗透压 365 mOsm/kg，无明显酮体，意识混乱。首要任务是什么？

  1. A谨慎静脉补液，并密切检查渗透压、血钠和血糖
  2. B大剂量静脉推注胰岛素，使血糖在一小时内降至正常
  3. C口服葡萄糖以防治疗期间发生低血糖
  4. D严格限制液体以避免脑水肿
13.内外科护理：消化、围手术期与肿瘤中等

Why are many patients screened for MRSA before planned surgery?

  1. ASo that carriers can be decolonised to reduce infection
  2. BTo decide which anaesthetic drug to use
  3. CTo check whether the patient has had a flu vaccine
  4. DSo that surgery can be cancelled for all positive patients
14.内外科护理：消化、围手术期与肿瘤困难

Four patients from a house fire arrive in the emergency department. Which should the nurse assess first?

  1. AA blistered forearm burn and a small cut on the knee
  2. BCircumferential chest burns, with breathing becoming shallow and laboured
  3. CPartial-thickness burns to both legs, with pain rated 8/10
  4. DRedness on the backs of both hands, and very anxious

3溶液

1.优先排序与委派

答案: B · 3 级

为什么是这个答案

血液检查（一种资源）加 CT 扫描（第二种资源）共两种资源，当生命体征可接受时为 ESI 3 级。

答案

B · 3 级
2.优先排序与委派

答案: C · Tell the charge nurse about the gap, accept tasks within competence and ask for support

为什么是这个答案

A nurse should clearly state the limits of their competence and ask for an assignment or support that keeps patients safe. Leaving without handover would be patient abandonment.

答案

C · Tell the charge nurse about the gap, accept tasks within competence and ask for support
3.感染控制与患者安全

答案: A · 使外观相似的药名更容易区分

为什么是这个答案

Tall Man 标注法把相似药名中不同的字母用大写表示，使工作人员在阅读标签、屏幕和医嘱时能注意到差异。

答案

A · 使外观相似的药名更容易区分
4.感染控制与患者安全

答案: D · Alert staff and security at once, following the missing-patient procedure

为什么是这个答案

A missing vulnerable patient is an emergency. The nurse immediately activates the facility’s missing-patient procedure so a search starts, and the provider and family are informed per policy.

答案

D · Alert staff and security at once, following the missing-patient procedure
5.实验室检查值与电解质

答案: A · Plasma volume rises more than red cell mass, diluting the blood

为什么是这个答案

In pregnancy, plasma volume increases by more than red cell mass, so the hemoglobin falls slightly (physiologic or dilutional anemia). Iron deficiency is still common in pregnancy and is checked with the MCV and ferritin.

答案

A · Plasma volume rises more than red cell mass, diluting the blood
6.实验室检查值与电解质

答案: A · Disseminated intravascular coagulation (DIC)

为什么是这个答案

In DIC, widespread clotting consumes platelets and clotting factors, so PT and aPTT are prolonged and fibrinogen falls, while clot breakdown raises the D-dimer. ITP lowers platelets only, and hemophilia A prolongs only the aPTT.

答案

A · Disseminated intravascular coagulation (DIC)
7.临床护理

答案: B · Fluid balance, regular weights and urea, creatinine and electrolytes

为什么是这个答案

IV fluids can cause overload or electrolyte imbalance. Fluid balance charts, weight, clinical assessment and blood tests guide the prescription.

答案

B · Fluid balance, regular weights and urea, creatinine and electrolytes
8.临床护理

答案: D · A base-of-skull fracture with a cerebrospinal fluid leak

为什么是这个答案

Clear fluid from the nose or ear after head injury suggests a CSF leak from a skull base fracture, with a risk of meningitis. Nasal tubes and nose-blowing should be avoided and the patient reviewed urgently.

答案

D · A base-of-skull fracture with a cerebrospinal fluid leak
9.内外科护理：心血管与呼吸

答案: A · Reduced peripheral perfusion

为什么是这个答案

Capillary refill time above about 2 seconds suggests poor peripheral perfusion, for example from dehydration, shock or cold. It should be interpreted with other signs such as heart rate, blood pressure, skin temperature and urine output.

答案

A · Reduced peripheral perfusion
10.内外科护理：心血管与呼吸

答案: B · Via a mask or humidified device over the neck stoma

为什么是这个答案

A total laryngectomy separates the trachea from the upper airway, so the patient breathes only through the neck stoma. Oxygen and any rescue breaths must be given via the stoma. These patients are "neck breathers" and often carry an alert card.

答案

B · Via a mask or humidified device over the neck stoma
11.内外科护理：神经、内分泌与肾脏

答案: D · 在专用的干热加温器中

为什么是这个答案

将透析液加温至体温可提高舒适度。微波炉加热不均匀，会产生热点；浸泡可能污染接口。应使用制造商认可的干热加温器。

答案

D · 在专用的干热加温器中
12.内外科护理：神经、内分泌与肾脏

答案: A · 谨慎静脉补液，并密切检查渗透压、血钠和血糖

为什么是这个答案

HHS 首先用静脉补液治疗，单靠补液往往就能降低血糖。渗透压迅速下降有脑水肿风险，所以要逐渐降低。如果有酮体，或补液后血糖不再下降，则以低速率加用胰岛素。由于血栓风险高，VTE 预防很重要。

答案

A · 谨慎静脉补液，并密切检查渗透压、血钠和血糖
13.内外科护理：消化、围手术期与肿瘤

答案: A · So that carriers can be decolonised to reduce infection

为什么是这个答案

MRSA carriers have a higher risk of surgical site infection. Screening allows decolonisation with nasal ointment and skin washes, and the right antibiotic prophylaxis.

答案

A · So that carriers can be decolonised to reduce infection
14.内外科护理：消化、围手术期与肿瘤

答案: B · Circumferential chest burns, with breathing becoming shallow and laboured

为什么是这个答案

Circumferential full-thickness burns of the chest form rigid eschar that restricts chest expansion and can cause respiratory failure. This patient needs immediate breathing assessment, senior help and possibly urgent escharotomy. The others need care but are not immediately life-threatening.

答案

B · Circumferential chest burns, with breathing becoming shallow and laboured

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