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 taking clozapine reports a sore throat and fever. What is the priority action?

  1. AAdvise the patient to gargle with warm salt water and rest in bed
  2. BHold the dose and report so the white cell count can be checked
  3. COffer throat lozenges and continue the usual dose
  4. DIncrease the dose because the symptoms suggest a relapse
2.优先排序与委派困难

一名患者 45 分钟前突然说话困难。哪项行动优先级最高？

  1. A等神经科医生在早晨查房时评估患者
  2. B立即口服阿司匹林以限制血栓
  3. C给水，让患者服用平常的早晨药物
  4. D启动卒中团队进行紧急影像学检查，并记录最后已知正常的时间
3.感染控制与患者安全中等

A nurse wants to set up a sterile field in the morning for a procedure that will take place after lunch. What is correct?

  1. ASet it up in the morning and ask a colleague to check it once
  2. BSet it up just before the procedure, because a waiting field may become contaminated
  3. CSet it up in the morning and leave it uncovered in an empty room
  4. DSet it up in the morning and cover it with a clean towel until the procedure starts
4.感染控制与患者安全困难

A patient’s white cell differential shows a raised number of band (immature) neutrophils, called a “shift to the left”. What does this usually suggest?

  1. AAn acute bacterial infection
  2. BAn allergic reaction
  3. CA long-standing parasitic infection
  4. DA typical viral infection
5.实验室检查值与电解质中等

A healthy patient's result is slightly outside the laboratory reference range, and all other results are normal. Which statement best explains why this can happen?

  1. ARanges cover about 95% of healthy people, so some fall outside
  2. BReference ranges are the same in every laboratory worldwide
  3. CAny result outside the range always means disease is present
  4. DReference ranges include every healthy person without exception
6.实验室检查值与电解质困难

一名患者的钾几个月来一直是 3.4–3.6 mEq/L，今天的一次结果是 5.4 mEq/L。患者感觉良好，心电图正常。最好的下一步是什么？

  1. A检查样本是如何采集的，评估患者并重复检测
  2. B不做进一步检查，立即开始使用钾结合剂
  3. C忽略该结果，因为患者感觉良好
  4. D停用患者所有的常规药物
7.临床护理中等

What should a patient starting oral iron tablets be told?

  1. ATheir stools may turn dark or black
  2. BThey must take the tablets with strong tea
  3. CThe tablets will cause weight loss
  4. DTheir urine will turn bright green
8.临床护理困难

一名全髋关节置换术后的患者突然出现剧烈髋部疼痛，下肢缩短并发生旋转。最可能的并发症是什么？

  1. A假体脱位
  2. B伤口感染
  3. C尿潴留
  4. D小腿深静脉血栓形成
9.内外科护理：心血管与呼吸中等

A patient with chest pain has a first troponin result within the normal range one hour after the pain started. Why is a repeat test arranged?

  1. AThe repeat test is only needed for patients over 80
  2. BTroponin falls during an MI, so a lower value confirms it
  3. CTroponin may take a few hours to rise after muscle damage
  4. DThe first sample is always contaminated
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. AAcute stent thrombosis
  2. BPericarditis from the catheter
  3. CNormal pain from the procedure site
  4. DIndigestion from the hospital meal
11.内外科护理：神经、内分泌与肾脏中等

A patient takes an SGLT2 inhibitor. Which sick-day advice is correct?

  1. AStop drinking fluids while taking the drug
  2. BKeep taking it as normal, whatever the illness
  3. CDouble the dose during illness to control the glucose
  4. DPause the drug during illness with vomiting or poor intake
12.内外科护理：神经、内分泌与肾脏困难

A nurse teaches foot care to a patient with diabetic neuropathy. Which statement shows a need for further teaching?

  1. A"I will check that the bath water is not too hot using my elbow."
  2. B"I will wear socks and shoes that fit well and do not rub."
  3. C"I will buy corn plasters from the pharmacy for my corn."
  4. D"I will check my feet every day, using a mirror for the soles."
13.内外科护理：消化、围手术期与肿瘤中等

Which nursing intervention best reduces preoperative anxiety?

  1. AExplaining what will happen and answering questions
  2. BKeeping family members away until after surgery
  3. CTelling the patient that there is nothing to worry about
  4. DAvoiding talking about the operation at all
14.内外科护理：消化、围手术期与肿瘤困难

A patient is booked for a urea breath test for H. pylori. Which medicine should usually be stopped 2 weeks before the test?

  1. AAmlodipine
  2. BLevothyroxine
  3. COmeprazole
  4. DParacetamol (acetaminophen)

3溶液

1.优先排序与委派

答案: B · Hold the dose and report so the white cell count can be checked

为什么是这个答案

Clozapine can cause agranulocytosis. A sore throat or fever may be the first sign of infection, so the nurse reports it and the neutrophil count is checked before more doses are given.

答案

B · Hold the dose and report so the white cell count can be checked
2.优先排序与委派

答案: D · 启动卒中团队进行紧急影像学检查，并记录最后已知正常的时间

为什么是这个答案

溶栓治疗与时间有关，且需要先做影像学检查以排除出血。最后已知正常的时间决定是否符合条件。影像学检查前不给阿司匹林，在吞咽筛查之前不经口给予任何东西。

答案

D · 启动卒中团队进行紧急影像学检查，并记录最后已知正常的时间
3.感染控制与患者安全

答案: B · Set it up just before the procedure, because a waiting field may become contaminated

为什么是这个答案

The longer a sterile field is exposed, the more likely it is to be contaminated, and an unattended field cannot be considered sterile. It is prepared just before use.

答案

B · Set it up just before the procedure, because a waiting field may become contaminated
4.感染控制与患者安全

答案: A · An acute bacterial infection

为什么是这个答案

In acute bacterial infection, the bone marrow releases neutrophils before they mature, raising the proportion of bands. Allergies and parasites raise eosinophils, and viral infections more often raise lymphocytes.

答案

A · An acute bacterial infection
5.实验室检查值与电解质

答案: A · Ranges cover about 95% of healthy people, so some fall outside

为什么是这个答案

A reference range is usually the central 95% of results from a healthy population, so about 1 in 20 healthy people will have a value just outside it. The result is interpreted with the clinical picture and previous values, and repeated if needed.核对依据: How to Understand Your Lab Results · MedlinePlus (NIH) (2025)

答案

A · Ranges cover about 95% of healthy people, so some fall outside
6.实验室检查值与电解质

答案: A · 检查样本是如何采集的，评估患者并重复检测

为什么是这个答案

突然孤立的升高可能是真实的变化，例如由新药或肾损伤引起，也可能是样本问题，如溶血或处理前延迟。护士应评估患者，通知医疗人员并安排重复检测。核对依据: Hyperkalemia · StatPearls (NCBI Bookshelf) (2025)

答案

A · 检查样本是如何采集的，评估患者并重复检测
7.临床护理

答案: A · Their stools may turn dark or black

为什么是这个答案

Oral iron commonly darkens the stool and can cause constipation or stomach upset. Tea and antacids reduce absorption, while vitamin C may increase it.

答案

A · Their stools may turn dark or black
8.临床护理

答案: A · 假体脱位

为什么是这个答案

关节置换术后髋关节脱位会引起突发疼痛、下肢缩短和旋转。需要紧急评估和复位；应教会患者活动注意事项。

答案

A · 假体脱位
9.内外科护理：心血管与呼吸

答案: C · Troponin may take a few hours to rise after muscle damage

为什么是这个答案

Troponin starts to rise within hours of myocardial injury, so a very early result can be normal. Protocols use serial measurements at set intervals, with the ECG and clinical picture, to diagnose or exclude MI. A rising pattern supports acute injury.

答案

C · Troponin may take a few hours to rise after muscle damage
10.内外科护理：心血管与呼吸

答案: A · 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

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

答案: D · Pause the drug during illness with vomiting or poor intake

为什么是这个答案

During dehydrating illness, SGLT2 inhibitors increase the risk of DKA, which can occur with only modestly raised glucose, and of acute kidney injury. Patients are taught to pause them until they are eating and drinking normally.

答案

D · Pause the drug during illness with vomiting or poor intake
12.内外科护理：神经、内分泌与肾脏

答案: C · "I will buy corn plasters from the pharmacy for my corn."

为什么是这个答案

Medicated corn plasters contain acids that can burn the skin and cause ulcers in people with neuropathy or poor circulation. Corns and calluses should be treated by a podiatrist.

答案

C · "I will buy corn plasters from the pharmacy for my corn."
13.内外科护理：消化、围手术期与肿瘤

答案: A · Explaining what will happen and answering questions

为什么是这个答案

Clear information about what to expect, including pain control and recovery, reduces anxiety and can improve recovery. False reassurance does not address the patient's concerns.

答案

A · Explaining what will happen and answering questions
14.内外科护理：消化、围手术期与肿瘤

答案: C · Omeprazole

为什么是这个答案

PPIs suppress H. pylori and can give false-negative breath or stool tests, so they are usually stopped 2 weeks before. Antibiotics are usually stopped 4 weeks before testing.

答案

C · Omeprazole

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