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。

新题目返回课程

在打印窗口中选择“另存为 PDF”，即可在设备上保存一份副本。

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

护士看到一名护理助理用明显太小的袖带测量血压。护士应怎么做？

  1. A在助理下一次年度考核时再提
  2. B当天让该助理停止接触患者
  3. C忽略，因为一次高读数无关紧要
  4. D立即介入，委婉地纠正操作，并重新测量
2.优先排序与委派困难

A victim heavily contaminated with an industrial chemical arrives at the emergency department with stable vital signs. What should happen first?

  1. AFull assessment inside the main department straight away
  2. BTaking the victim straight to the X-ray department
  3. CDecontamination before the victim enters the treatment area
  4. DPlacing the victim in the waiting room until a doctor is free
3.感染控制与患者安全中等

A colleague has drawn up a medication and asks the nurse to give it to her patient. What should the nurse do?

  1. ADecline, and give only medications that the nurse prepared or checked personally
  2. BGive it, and document that the colleague prepared it
  3. CGive it, as long as the syringe has a label with the drug name on it
  4. DGive it, because the colleague is experienced
4.感染控制与患者安全困难

A nurse teaches an older adult about preventing falls at home. Which statement shows a need for further teaching?

  1. A“I use night lights between my bedroom and the bathroom.”
  2. B“I wear shoes with non-slip soles around the house.”
  3. C“I keep small rugs in the hall so my feet stay warm.”
  4. D“I had grab bars put in next to the toilet.”
5.实验室检查值与电解质中等

A healthy patient has a mildly raised CK after running a marathon yesterday, without dark urine or symptoms. What is the most likely explanation?

  1. AThe patient has developed acute hepatitis
  2. BStrenuous exercise raised CK from skeletal muscle
  3. CAn acute myocardial infarction has occurred
  4. DThe patient has developed acute pancreatitis
6.实验室检查值与电解质困难

一名严重呕吐的患者钾 3.0 mEq/L，氯 88 mEq/L，碳酸氢盐高。这显示什么模式？

  1. A胃酸丢失：低钾、低氯、代谢性碱中毒
  2. B高钾伴脱水所致的代谢性酸中毒
  3. C结果正常，无需随访
  4. D伴高阴离子间隙的糖尿病酮症酸中毒
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. AIn any position, as long as the feed runs slowly
  2. BLying completely flat
  3. CWith the head of the bed raised to at least 30 degrees
  4. DLying on the left side with the head down to help the feed drain
8.临床护理困难

肠切除术后两天，一名患者疼痛加重、发热、心动过速，伤口引流管中的液体看起来像粪便。最可能发生了什么？

  1. A便秘
  2. B正常的术后恢复
  3. C吻合口瘘
  4. D尿潴留
9.内外科护理：心血管与呼吸中等

关于阿哌沙班和利伐沙班等直接口服抗凝药，下列哪项说法正确？

  1. A给予维生素 K 可逆转其作用
  2. B无需常规检测 INR，但剂量取决于肾功能
  3. C需要像华法林一样每周检测 INR
  4. D漏服无关紧要，因为它们的作用可持续数周
10.内外科护理：心血管与呼吸困难

A ventilated patient is coughing, and the high-pressure alarm sounds. Coarse sounds are heard over the trachea. What should the nurse do first?

  1. ATurn the alarm off and reassess the patient in an hour
  2. BDeflate the endotracheal tube cuff fully
  3. CAssess the patient and suction if secretions are present
  4. DIncrease the tidal volume on the ventilator to overcome it
11.内外科护理：神经、内分泌与肾脏中等

After a change in the levothyroxine dose, when is the TSH usually rechecked?

  1. AAfter 24 hours
  2. BAfter about 2 years of treatment
  3. CAfter about 6–8 weeks
  4. DAfter 3 days
12.内外科护理：神经、内分泌与肾脏困难

A patient on levothyroxine has palpitations, weight loss and poor sleep. TSH is suppressed, and free T4 is high. What is the most likely explanation?

  1. AThe thyroid has stopped working
  2. BThe dose is too low
  3. CThe dose is too high
  4. DA normal response to the drug
13.内外科护理：消化、围手术期与肿瘤中等

Before an anti-TNF biologic such as infliximab is started for Crohn's disease, which screening is essential?

  1. AA test of colour vision
  2. BScreening for tuberculosis
  3. CA test for coeliac disease
  4. DA bone density scan
14.内外科护理：消化、围手术期与肿瘤困难

一名已知有食管静脉曲张的患者呕出大量鲜血。内镜检查前，护士应预期哪些治疗？

  1. A在复苏期间使用奥曲肽或特利加压素，并加用静脉抗生素
  2. B口服 NSAID 止痛和高蛋白饮食
  3. C在任何药物治疗前紧急做钡餐吞咽检查
  4. D快速输注生理盐水至高血压

3溶液

1.优先排序与委派

答案: D · 立即介入，委婉地纠正操作，并重新测量

为什么是这个答案

监督包括立即以尊重的方式纠正错误，并获得准确的数值。过小的袖带会高估血压。忽略或等上几个月都会让伤害持续存在。

答案

D · 立即介入，委婉地纠正操作，并重新测量
2.优先排序与委派

答案: C · Decontamination before the victim enters the treatment area

为什么是这个答案

A stable, contaminated victim is decontaminated before entering the department, to protect staff, other patients and the victim. Life-saving care may come first only if the victim is unstable.

答案

C · Decontamination before the victim enters the treatment area
3.感染控制与患者安全

答案: A · Decline, and give only medications that the nurse prepared or checked personally

为什么是这个答案

Nurses give only medicines they prepared themselves or verified fully, because they are accountable for what they give. A drug prepared by someone else may be wrong in ways the nurse cannot see.

答案

A · Decline, and give only medications that the nurse prepared or checked personally
4.感染控制与患者安全

答案: C · “I keep small rugs in the hall so my feet stay warm.”

为什么是这个答案

Loose rugs are a common cause of trips and falls and should be removed or secured. Night lights, grab bars and non-slip footwear all reduce fall risk.

答案

C · “I keep small rugs in the hall so my feet stay warm.”
5.实验室检查值与电解质

答案: B · Strenuous exercise raised CK from skeletal muscle

为什么是这个答案

Strenuous exercise, IM injections and muscle trauma can raise CK from skeletal muscle. A very high CK with dark urine suggests rhabdomyolysis, and heart damage is assessed with troponin, not CK.核对依据: Creatine Kinase · MedlinePlus (NIH) (2023); Creatine phosphokinase test · MedlinePlus (NIH) (2025)

答案

B · Strenuous exercise raised CK from skeletal muscle
6.实验室检查值与电解质

答案: A · 胃酸丢失：低钾、低氯、代谢性碱中毒

为什么是这个答案

呕吐丢失盐酸，因此氯下降、碳酸氢盐升高（代谢性碱中毒）。随后肾脏丢失钾。补充通常包括按处方使用含钾的 0.9% 氯化钠。核对依据: Alkalosis · StatPearls (NCBI Bookshelf) (2024)

答案

A · 胃酸丢失：低钾、低氯、代谢性碱中毒
7.临床护理

答案: C · 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

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

答案: C · 吻合口瘘

为什么是这个答案

吻合口瘘使肠内容物进入腹腔，引起腹膜炎和脓毒症。这是需要紧急评估的外科急症。

答案

C · 吻合口瘘
9.内外科护理：心血管与呼吸

答案: B · 无需常规检测 INR，但剂量取决于肾功能

为什么是这个答案

DOAC 的作用可预测，因此不需要常规的凝血监测。剂量取决于肾功能、体重、年龄和相互作用的药物。由于药效在一两天内消退，漏服很重要。维生素 K 不能逆转其作用；有特异性的逆转剂。

答案

B · 无需常规检测 INR，但剂量取决于肾功能
10.内外科护理：心血管与呼吸

答案: C · Assess the patient and suction if secretions are present

为什么是这个答案

High-pressure alarms are caused by secretions, coughing, biting the tube, kinked tubing or bronchospasm. With secretions heard, suctioning is the logical first step after a quick assessment. Low-pressure alarms suggest a leak or disconnection. Alarms must never be silenced without finding the cause.

答案

C · Assess the patient and suction if secretions are present
11.内外科护理：神经、内分泌与肾脏

答案: C · After about 6–8 weeks

为什么是这个答案

Levothyroxine has a half-life of about a week, so it takes several weeks to reach a new steady state. TSH is usually rechecked about 6–8 weeks after a dose change.

答案

C · After about 6–8 weeks
12.内外科护理：神经、内分泌与肾脏

答案: C · The dose is too high

为什么是这个答案

A suppressed TSH with raised free T4 and hyperthyroid symptoms in a patient on levothyroxine suggests over-replacement. The prescriber usually lowers the dose. Long-term over-replacement increases the risk of atrial fibrillation and bone loss.

答案

C · The dose is too high
13.内外科护理：消化、围手术期与肿瘤

答案: B · Screening for tuberculosis

为什么是这个答案

Anti-TNF drugs suppress immunity and can reactivate latent tuberculosis. Patients are screened for TB and hepatitis B before starting and are taught to report signs of infection.

答案

B · Screening for tuberculosis
14.内外科护理：消化、围手术期与肿瘤

答案: A · 在复苏期间使用奥曲肽或特利加压素，并加用静脉抗生素

为什么是这个答案

在疑似静脉曲张出血时，血管活性药物（美国用奥曲肽，或在已获批准的地区用特利加压素）降低门静脉压，预防性使用头孢曲松等抗生素可减少肝硬化患者的感染和死亡。复苏应谨慎，以免升高门静脉压。内镜下套扎是确定性治疗。

答案

A · 在复苏期间使用奥曲肽或特利加压素，并加用静脉抗生素

本内容为独立练习材料。ExamProblems 与该考试的主办机构没有隶属关系，也未获其认可，考试名称仅用于描述内容。 NCLEX®, NCLEX-RN® and NCLEX-PN® 是 the National Council of State Boards of Nursing, Inc. (NCSBN) 的商标，该机构与 ExamProblems 无关，不为其背书，也不保证其准确性。

ExamProblems · examproblems.com/courses/nclex-style-prioritization-and-delegation