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

Which patient is at the highest risk of falling?

  1. AA 60-year-old admitted for chest pain that has since been ruled out by tests
  2. BA 45-year-old with asthma who is alert and independent
  3. CA 30-year-old after an appendectomy who walks with steady steps
  4. DAn 84-year-old taking a diuretic who has fallen before and gets up at night
2.优先排序与委派困难

Which patient is the best choice for the room closest to the nurses’ station?

  1. AA patient admitted for a planned scan, feeling well
  2. BA young adult waiting for discharge tomorrow
  3. CA confused older adult at high risk of falls
  4. DA patient with stable diabetes who walks independently
3.感染控制与患者安全中等

Before a blood transfusion is started, which check is required?

  1. AThe patient’s identity is checked against the blood product and its paperwork at the bedside
  2. BThe nurse checks only that the bag number matches the order
  3. CThe patient signs the blood bag label to confirm their name before it is hung
  4. DOne nurse checks the blood product against the order at the nurses’ station
4.感染控制与患者安全困难

The fire alarm sounds, but the nurse does not know where the fire is. What should the nurse do?

  1. AEvacuate all patients down the stairs at once, starting with those in bed
  2. BLeave the unit and the building to find out where the fire is
  3. COpen all doors so patients can be seen easily
  4. DClose the doors to patient rooms, stay on the unit and wait for instructions
5.实验室检查值与电解质中等

A week after a splenectomy, a patient's platelet count is 650 × 10³/µL. What is the best interpretation?

  1. AA sign of new leukemia that needs immediate chemotherapy
  2. BAn expected rise after splenectomy that increases clot risk
  3. CA laboratory error, because platelets fall after splenectomy
  4. DA sign of iron overload from the surgery and transfusion
6.实验室检查值与电解质困难

一名患者 24 小时前大量过量服用对乙酰氨基酚（扑热息痛）。最预期出现哪些实验室改变？

  1. AALT 和 AST 非常高，INR 上升
  2. B肌钙蛋白高而 ALT 正常
  3. CALT 和 AST 低，INR 低
  4. D白细胞计数低而肝功能检查正常
7.临床护理中等

一名肝硬化患者出现意识混乱、嗜睡，双手有扑翼样震颤。可能发生了哪种并发症？

  1. A肝性脑病
  2. B卒中
  3. C胰岛素引起的低血糖
  4. D单纯酒精中毒
8.临床护理困难

A patient with small cell lung cancer has hyponatraemia, concentrated urine and no signs of dehydration. Which condition and first measure fit best?

  1. ADehydration, managed with an IV fluid bolus
  2. BDiabetes insipidus, managed with extra fluids
  3. CSIADH, often managed first with fluid restriction
  4. DCushing's syndrome, managed with potassium
9.内外科护理：心血管与呼吸中等

D-二聚体升高意味着什么？

  1. A已安全排除深静脉血栓形成
  2. B存在纤维蛋白降解，但不能证明有血栓
  3. C已确诊肺栓塞或 DVT
  4. D抗凝药剂量过低，必须增加
10.内外科护理：心血管与呼吸困难

心肌梗死三周后，一名患者出现发热、胸膜性胸痛（前倾时减轻）和心包摩擦音。最可能的诊断是什么？

  1. A心肌梗死后（Dressler）综合征
  2. B另一条动脉的新发 STEMI
  3. C急性主动脉夹层
  4. D急性左心衰竭
11.内外科护理：神经、内分泌与肾脏中等

A patient taking warfarin is diagnosed with an intracerebral haemorrhage. What is the priority treatment?

  1. AIV thrombolysis within 4.5 hours
  2. BUrgent reversal of the anticoagulant effect
  3. CDoubling the warfarin dose to stabilise the INR
  4. DStarting aspirin to prevent further clots
12.内外科护理：神经、内分泌与肾脏困难

A patient with an external ventricular drain sat up in bed without help. The drain stayed at its old height, and the drainage bag filled quickly. The patient now has a headache. What is the concern?

  1. AUnderdrainage, so the drain should be lowered further
  2. BOverdrainage of CSF, so act per protocol and inform the team
  3. CNo concern, because more drainage always lowers the ICP safely
  4. DAn infected drain, so the dressing should be removed
13.内外科护理：消化、围手术期与肿瘤中等

Which is a recognised cause of anaphylaxis during surgery?

  1. AA warmed blanket
  2. BThe patient's own blood from cell salvage
  3. CChlorhexidine skin preparation
  4. DSterile normal saline
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快速输注生理盐水至高血压
  3. C口服 NSAID 止痛和高蛋白饮食
  4. D在任何药物治疗前紧急做钡餐吞咽检查

3溶液

1.优先排序与委派

答案: D · An 84-year-old taking a diuretic who has fallen before and gets up at night

为什么是这个答案

A previous fall is one of the strongest risk factors. Older age, diuretics and getting up at night to urinate add further risk, so this patient needs fall precautions.

答案

D · An 84-year-old taking a diuretic who has fallen before and gets up at night
2.优先排序与委派

答案: C · A confused older adult at high risk of falls

为什么是这个答案

A confused patient at high risk of falls benefits from being close to staff, so they can be observed and helped quickly. The other patients are stable and independent.

答案

C · A confused older adult at high risk of falls
3.感染控制与患者安全

答案: A · The patient’s identity is checked against the blood product and its paperwork at the bedside

为什么是这个答案

Wrong-patient transfusion can cause a fatal ABO reaction, so the final check is always done at the bedside, with positive patient identification against the product label, compatibility tag and order. Many US hospitals require two qualified people for this check, while UK guidance allows one trained person if positive identification is used. Local policy decides who checks.

答案

A · The patient’s identity is checked against the blood product and its paperwork at the bedside
4.感染控制与患者安全

答案: D · Close the doors to patient rooms, stay on the unit and wait for instructions

为什么是这个答案

Closing doors limits the spread of smoke and fire. Staff follow the fire plan, keep corridors clear and prepare for evacuation, but do not evacuate until directed or the fire is in their area.

答案

D · Close the doors to patient rooms, stay on the unit and wait for instructions
5.实验室检查值与电解质

答案: B · An expected rise after splenectomy that increases clot risk

为什么是这个答案

The spleen stores about a third of the platelets. After splenectomy, the count often rises (reactive thrombocytosis), which can increase the risk of thrombosis. The count is monitored, and the patient is assessed for signs of clots.核对依据: Platelet count · MedlinePlus (NIH) (2025); Platelet Tests · MedlinePlus (NIH) (2024)

答案

B · An expected rise after splenectomy that increases clot risk
6.实验室检查值与电解质

答案: A · ALT 和 AST 非常高，INR 上升

为什么是这个答案

中毒剂量损害肝细胞，因此 ALT 和 AST 急剧升高，肝衰竭使 INR 升高。乙酰半胱氨酸是解毒剂，早期给予效果最好。核对依据: Acetaminophen Toxicity · StatPearls (NCBI Bookshelf) (2026)

答案

A · ALT 和 AST 非常高，INR 上升
7.临床护理

答案: A · 肝性脑病

为什么是这个答案

肝性脑病引起意识混乱和扑翼样震颤。常用乳果糖减少氨的吸收，并治疗感染或出血等诱因。

答案

A · 肝性脑病
8.临床护理

答案: C · SIADH, often managed first with fluid restriction

为什么是这个答案

In SIADH, excess ADH makes the kidneys retain water, so blood sodium is diluted while urine is concentrated. Small cell lung cancer is a classic cause; fluid restriction is a common first step.

答案

C · SIADH, often managed first with fluid restriction
9.内外科护理：心血管与呼吸

答案: B · 存在纤维蛋白降解，但不能证明有血栓

为什么是这个答案

D-二聚体是纤维蛋白的降解产物。临床可能性低（例如 Wells 评分低）的患者结果正常，有助于排除 DVT 或 PE。许多情况下都会升高，因此需要影像学检查（双功能超声或 CT 肺动脉造影）来确认血栓。

答案

B · 存在纤维蛋白降解，但不能证明有血栓
10.内外科护理：心血管与呼吸

答案: A · 心肌梗死后（Dressler）综合征

为什么是这个答案

Dressler 综合征是心肌梗死数周后发生的免疫介导性心包炎，表现为发热、坐起前倾时缓解的胸膜性疼痛和摩擦音。在再灌注时代现已少见。新的梗死引起的缺血性疼痛不随体位改变，夹层引起放射到背部的撕裂样疼痛。

答案

A · 心肌梗死后（Dressler）综合征
11.内外科护理：神经、内分泌与肾脏

答案: B · Urgent reversal of the anticoagulant effect

为什么是这个答案

Anticoagulants make the haematoma expand. Warfarin is reversed urgently, typically with prothrombin complex concentrate and IV vitamin K. Thrombolysis and antiplatelets are contraindicated in a bleed.

答案

B · Urgent reversal of the anticoagulant effect
12.内外科护理：神经、内分泌与肾脏

答案: B · Overdrainage of CSF, so act per protocol and inform the team

为什么是这个答案

When the head rises above the drain level, CSF drains faster. Overdrainage can cause headache, collapse of the ventricles or a subdural bleed. The nurse follows the protocol (often clamping briefly and re-levelling) and informs the neurosurgical team.

答案

B · Overdrainage of CSF, so act per protocol and inform the team
13.内外科护理：消化、围手术期与肿瘤

答案: C · Chlorhexidine skin preparation

为什么是这个答案

Common causes of perioperative anaphylaxis include neuromuscular blockers, antibiotics, chlorhexidine and latex. Allergies are documented, and suspected reactions are investigated afterwards.

答案

C · Chlorhexidine skin preparation
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

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