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 has a reddened area on the sacrum that does not blanch when pressed. What is the priority action?

  1. ARelieve pressure on the area by changing position regularly
  2. BApply a heat pad to the area to increase circulation
  3. CMassage the area firmly to improve the blood flow to the skin
  4. DKeep the patient lying on the back to protect the area
2.优先排序与委派困难

A patient’s serum potassium is 6.1 mEq/L. Which of the patient’s medications should the nurse question first?

  1. AOmeprazole
  2. BFurosemide
  3. CHydrochlorothiazide
  4. DSpironolactone
3.感染控制与患者安全中等

A patient with a fentanyl skin patch wants to use a heating pad on the area. What should the nurse teach?

  1. AHeat makes the patch last longer, so fewer patches are needed each month
  2. BHeat is fine to use, because it helps the patch stick better to the skin
  3. CAvoid heat on or near the patch, because it increases how fast the drug is absorbed
  4. DHeat only matters if the patch is on the chest
4.感染控制与患者安全困难

一名活动性肺结核患者要求访客进来探视。最佳回应是什么？

  1. A请访客站在敞开的门口，而不进入房间
  2. B永久禁止一切接触，包括电话
  3. C解释风险，限制探视，并教访客使用所提供的防护
  4. D为了支持患者，让任何访客不加任何预防措施地进入
5.实验室检查值与电解质中等

A tired patient with heavy menstrual periods has a normal hemoglobin and MCV but a ferritin of 8 ng/mL. What does this show?

  1. AA completely normal iron status
  2. BIron overload from too much iron
  3. CIron deficiency without anemia yet
  4. DVitamin B12 deficiency anemia
6.实验室检查值与电解质困难

A patient without symptoms has a finger-stick glucose of 340 mg/dL (18.9 mmol/L). The previous values were normal, and the patient has just peeled an orange. What should the nurse do first?

  1. AReport the result as a new diagnosis of diabetes mellitus
  2. BAsk the laboratory to measure HbA1c from the same drop of blood
  3. CHave the patient wash and dry their hands, then repeat the test
  4. DGive a correction dose of insulin for a glucose of 340 mg/dL
7.临床护理中等

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

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

A severely hypothermic patient is in cardiac arrest. Why is resuscitation usually continued until they are rewarmed?

  1. ACold patients cannot be defibrillated at all, so CPR is the only possible treatment
  2. BAdrenaline works better in cold patients
  3. CHypothermia always causes brain death quickly
  4. DThe cold protects the brain, so recovery may be possible after long resuscitation
9.内外科护理：心血管与呼吸中等

心肌梗死两天后，一名患者突发呼吸困难、出现湿啰音和新的响亮收缩期杂音。应怀疑哪种并发症？

  1. A乳头肌断裂伴急性二尖瓣反流
  2. B长期卧床引起的肺栓塞
  3. C由应激诱发的新发稳定型心绞痛
  4. D梗死后心包炎引起心包摩擦音
10.内外科护理：心血管与呼吸困难

A patient with a confirmed type A aortic dissection is hypertensive and tachycardic while awaiting surgery. Which drug class is usually given first to lower the heart rate and blood pressure?

  1. AOral aspirin
  2. BAn intravenous fluid bolus
  3. CAn intravenous beta-blocker
  4. DAn intravenous thrombolytic
11.内外科护理：神经、内分泌与肾脏中等

A man starts tamsulosin for BPH. Which teaching point is most important?

  1. AExpect the drug to shrink the prostate within a day
  2. BTake it with grapefruit juice to make it work better
  3. CStand up slowly, because it can make you dizzy
  4. DStop it if the urine stream improves
12.内外科护理：神经、内分泌与肾脏困难

A man who takes tamsulosin for BPH is listed for cataract surgery. Which statement is correct?

  1. AIt should be swapped for oxybutynin the night before to protect the eye
  2. BThe dose should be doubled before surgery to prevent urinary retention
  3. CThe eye surgeon must be told, as it can cause floppy iris during surgery
  4. DTamsulosin has no effects outside the urinary tract, so nothing changes
13.内外科护理：消化、围手术期与肿瘤中等

What does "neoadjuvant" treatment mean?

  1. ATreatment given only for pain relief
  2. BTreatment before the main treatment, often to shrink the tumour
  3. CTreatment that is given only after the cancer has already spread
  4. DTreatment that is given instead of any surgery
14.内外科护理：消化、围手术期与肿瘤困难

通过外周套管针静脉输注长春新碱时，患者报告灼痛，输注部位肿胀。护士首先应做什么？

  1. A用生理盐水冲洗套管针，把残留药物推入静脉
  2. B停止输注，保留套管针以回抽，并遵循规程
  3. C立即拔除套管针并按摩该区域以扩散药物
  4. D减慢速度继续输注，并在该部位敷冰袋

3溶液

1.优先排序与委派

答案: A · Relieve pressure on the area by changing position regularly

为什么是这个答案

Non-blanching redness is a stage 1 pressure injury. Relieving pressure through repositioning and support surfaces is the priority; massage can damage tissue further.

答案

A · Relieve pressure on the area by changing position regularly
2.优先排序与委派

答案: D · Spironolactone

为什么是这个答案

Spironolactone is a potassium-sparing diuretic and can raise potassium further. Furosemide and thiazides tend to lower potassium, and omeprazole does not usually affect it.

答案

D · Spironolactone
3.感染控制与患者安全

答案: C · Avoid heat on or near the patch, because it increases how fast the drug is absorbed

为什么是这个答案

Heat from heating pads, electric blankets, hot tubs or fever increases fentanyl absorption and can cause an overdose. Patients are taught to avoid heat over the patch.

答案

C · Avoid heat on or near the patch, because it increases how fast the drug is absorbed
4.感染控制与患者安全

答案: C · 解释风险，限制探视，并教访客使用所提供的防护

为什么是这个答案

应依据规定限制探视，辅以教育和防护，患者仍留在关闭的负压病房中。在敞开的门口探视会破坏负压。

答案

C · 解释风险，限制探视，并教访客使用所提供的防护
5.实验室检查值与电解质

答案: C · Iron deficiency without anemia yet

为什么是这个答案

Iron stores (ferritin) are depleted before the hemoglobin falls. A low ferritin with a normal hemoglobin indicates iron deficiency without anemia, and it is usually treated, along with the cause of blood loss.

答案

C · Iron deficiency without anemia yet
6.实验室检查值与电解质

答案: C · Have the patient wash and dry their hands, then repeat the test

为什么是这个答案

Sugar residue on the fingers can give a falsely high finger-stick result. The hands are washed with soap and water and dried, and the test repeated. If the value is still high, it is confirmed and reported. Treating a false result could cause hypoglycemia.

答案

C · Have the patient wash and dry their hands, then repeat the test
7.临床护理

答案: C · 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

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

答案: D · The cold protects the brain, so recovery may be possible after long resuscitation

为什么是这个答案

Hypothermia reduces the brain's oxygen needs, and good recoveries have occurred after long resuscitation. Death is usually not confirmed until the patient has been rewarmed, unless injuries are clearly not survivable.

答案

D · The cold protects the brain, so recovery may be possible after long resuscitation
9.内外科护理：心血管与呼吸

答案: A · 乳头肌断裂伴急性二尖瓣反流

为什么是这个答案

心肌梗死后乳头肌（或室间隔）破裂会产生新的杂音，并引起突发心力衰竭或休克。这是外科急症。心包炎引起的是胸膜性胸痛和摩擦音，而不是伴新杂音的急性肺水肿。

答案

A · 乳头肌断裂伴急性二尖瓣反流
10.内外科护理：心血管与呼吸

答案: C · An intravenous beta-blocker

为什么是这个答案

In acute dissection, IV beta-blockers are usually given first to reduce heart rate and the rate of rise of pressure, limiting extension of the tear. Vasodilators may follow once the heart rate is controlled. Antiplatelets, anticoagulants and thrombolytics are avoided. Type A dissection needs urgent surgery.

答案

C · An intravenous beta-blocker
11.内外科护理：神经、内分泌与肾脏

答案: C · Stand up slowly, because it can make you dizzy

为什么是这个答案

Tamsulosin relaxes smooth muscle in the prostate and bladder neck, improving urine flow within days. It can cause postural hypotension and dizziness, especially after the first dose, so patients rise slowly.

答案

C · Stand up slowly, because it can make you dizzy
12.内外科护理：神经、内分泌与肾脏

答案: C · The eye surgeon must be told, as it can cause floppy iris during surgery

为什么是这个答案

Tamsulosin blocks alpha-1A receptors in the iris dilator muscle as well as in the prostate, which can cause intraoperative floppy iris syndrome during cataract surgery. The effect can persist after the drug is stopped, so the surgeon must know in advance to plan the operation. Whether to pause it is a decision for the team.

答案

C · The eye surgeon must be told, as it can cause floppy iris during surgery
13.内外科护理：消化、围手术期与肿瘤

答案: B · Treatment before the main treatment, often to shrink the tumour

为什么是这个答案

Neoadjuvant chemotherapy or radiotherapy is given before surgery to shrink the tumour, which may make surgery easier or allow less extensive surgery. Adjuvant therapy follows surgery.

答案

B · Treatment before the main treatment, often to shrink the tumour
14.内外科护理：消化、围手术期与肿瘤

答案: B · 停止输注，保留套管针以回抽，并遵循规程

为什么是这个答案

发疱剂外渗可造成严重的组织损伤。应立即停止输注，尝试通过套管针回抽药物，然后遵循具体规程（长春碱类如长春新碱通常采用热敷，可能使用透明质酸酶，而蒽环类药物通常采用冷敷），抬高肢体，记录并通知团队。

答案

B · 停止输注，保留套管针以回抽，并遵循规程

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