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 nasogastric tube has just been placed for feeding. What must happen before the first feed is given?

  1. APlacement is confirmed by an approved method
  2. BThe tube is flushed with a large volume of water
  3. CThe patient is asked if the tube feels comfortable
  4. DThe feed is started slowly to see if the patient coughs
2.优先排序与委派困难

一名护士正在护理四位患者。可以安全地将谁分配给护理助理进行常规护理？

  1. A卒中后五天、需要协助洗澡且生命体征稳定的患者
  2. B手术返回、需要进行首次术后评估的患者
  3. C一小时前新置入胸腔引流管的患者
  4. D血糖 52 mg/dL（2.9 mmol/L）并出汗的患者
3.感染控制与患者安全中等

在台面上打开无菌包时，应先打开哪一片包布？

  1. A离护士最近的一片
  2. B离护士最远的一片
  3. C同时打开所有包布
  4. D最容易够到的那片侧边包布
4.感染控制与患者安全困难

A patient’s white cell differential shows a raised eosinophil count. Which cause is most consistent with this finding?

  1. ABone marrow suppression from chemotherapy
  2. BA viral infection such as a cold
  3. CAn acute bacterial infection
  4. DAn allergic reaction or a parasitic infection
5.实验室检查值与电解质中等

一名患者钠为 124 mEq/L，头痛并新出现意识模糊。哪项护理措施最恰当？

  1. A让患者平卧，并将神经系统检查限制为每班一次
  2. B鼓励患者多喝白开水
  3. C提前给予处方的噻嗪类利尿剂
  4. D采取癫痫预防措施并监测神经系统状态
6.实验室检查值与电解质困难

A patient with long-term heavy alcohol use is admitted with alcohol withdrawal. Which group of electrolyte problems is most common?

  1. AHigh sodium, high calcium and high glucose
  2. BHigh magnesium, high phosphate and high potassium
  3. CLow magnesium, low phosphate and low potassium
  4. DLow chloride, high bicarbonate and high calcium
7.临床护理中等

Under the Mental Capacity Act 2005 (England and Wales), which principle applies?

  1. AEveryone over 75 is assumed to lack capacity
  2. BA diagnosis of dementia means the person lacks capacity for all decisions
  3. CA person must be assumed to have capacity unless it is shown that they lack it
  4. DCapacity is decided by the next of kin, who must sign a form for every decision
8.临床护理困难

A patient with full mental capacity decides against a treatment that the team thinks is best. What does the Mental Capacity Act 2005 (England and Wales) say?

  1. AThe team may override any decision that it disagrees with if it is serious
  2. BA person is not treated as lacking capacity just because they make an unwise decision
  3. CThe patient must be assessed by a psychiatrist before refusing
  4. DThe family may make the decision instead if they disagree with the patient's choice
9.内外科护理：心血管与呼吸中等

A patient has just started an ACE inhibitor. Which blood tests are usually checked within the first one to two weeks?

  1. AINR and platelet count
  2. BLiver enzymes and amylase
  3. CTroponin and creatine kinase
  4. DPotassium and creatinine
10.内外科护理：心血管与呼吸困难

A patient with life-threatening asthma has not responded to repeated nebulised salbutamol (albuterol), ipratropium and steroids. Which drug is commonly given intravenously next?

  1. AMetoprolol
  2. BMagnesium sulfate
  3. CIntravenous furosemide
  4. DMorphine
11.内外科护理：神经、内分泌与肾脏中等

Why are tacrolimus blood levels checked regularly?

  1. AThe levels show how much urine the kidney is making
  2. BThe drug only works if levels are as high as possible
  3. CToo high harms the kidney; too low risks rejection
  4. DThe levels show whether the patient has diabetes
12.内外科护理：神经、内分泌与肾脏困难

A patient with hypopituitarism needs both hydrocortisone and levothyroxine. Which is usually started first?

  1. ANeither, until symptoms appear
  2. BLevothyroxine
  3. CHydrocortisone
  4. DBoth on the same day, in any order
13.内外科护理：消化、围手术期与肿瘤中等

哪种敷料通常适用于渗出液多的伤口？

  1. A每周更换的干纱布
  2. B水凝胶片
  3. C藻酸盐或泡沫
  4. D薄的透明薄膜
14.内外科护理：消化、围手术期与肿瘤困难

A patient on chemotherapy has white plaques on the tongue and cheeks that wipe off to leave red areas. What is most likely?

  1. ANormal mucositis healing
  2. BFood residue only
  3. CLeukoplakia from smoking
  4. DOral candidiasis

3溶液

1.优先排序与委派

答案: A · Placement is confirmed by an approved method

为什么是这个答案

A newly placed feeding tube can enter the airway without obvious symptoms, so placement is confirmed before anything is given. Methods differ: US practice usually requires an X-ray for a new feeding tube, while UK guidance uses aspirate pH testing (5.5 or below) first, with X-ray if that fails. Air “whoosh” tests and waiting for coughing are not reliable.

答案

A · Placement is confirmed by an approved method
2.优先排序与委派

答案: A · 卒中后五天、需要协助洗澡且生命体征稳定的患者

为什么是这个答案

需要日常生活活动协助的稳定患者适合由助理提供常规护理。新置入的胸腔引流管、有症状的低血糖和首次术后评估需要持证护士。

答案

A · 卒中后五天、需要协助洗澡且生命体征稳定的患者
3.感染控制与患者安全

答案: B · 离护士最远的一片

为什么是这个答案

先打开远端的包布，然后是两侧的包布，最后是近端的包布，这样护士就不会越过已暴露的无菌区伸手。

答案

B · 离护士最远的一片
4.感染控制与患者安全

答案: D · An allergic reaction or a parasitic infection

为什么是这个答案

Eosinophils rise in allergic conditions such as asthma and drug reactions and in parasitic infections. Acute bacterial infection mainly raises neutrophils, and viral infection often raises lymphocytes.

答案

D · An allergic reaction or a parasitic infection
5.实验室检查值与电解质

答案: D · 采取癫痫预防措施并监测神经系统状态

为什么是这个答案

低钠血症可引起脑水肿和惊厥。护士应监测神经系统状态，采取癫痫预防措施并报告结果。额外的水和噻嗪类药物会使钠进一步降低。核对依据: Low blood sodium · MedlinePlus (NIH) (2025)

答案

D · 采取癫痫预防措施并监测神经系统状态
6.实验室检查值与电解质

答案: C · Low magnesium, low phosphate and low potassium

为什么是这个答案

Poor diet, vomiting, diarrhea and alcohol's effect on the kidneys commonly cause low magnesium, phosphate and potassium. These worsen arrhythmia and seizure risk, so they are checked and replaced, together with thiamine.

答案

C · Low magnesium, low phosphate and low potassium
7.临床护理

答案: C · A person must be assumed to have capacity unless it is shown that they lack it

为什么是这个答案

The Act begins by presuming capacity. Capacity is decision-specific and time-specific, and people must be given all practicable help to make their own decision.

答案

C · A person must be assumed to have capacity unless it is shown that they lack it
8.临床护理

答案: B · A person is not treated as lacking capacity just because they make an unwise decision

为什么是这个答案

One of the Act's principles is that making an unwise decision is not, on its own, evidence of incapacity. The team should check understanding, explore reasons and document the discussion.

答案

B · A person is not treated as lacking capacity just because they make an unwise decision
9.内外科护理：心血管与呼吸

答案: D · Potassium and creatinine

为什么是这个答案

ACE inhibitors lower aldosterone, so potassium can rise, and they reduce glomerular filtration pressure, so creatinine can rise, especially with renal artery stenosis or dehydration. Baseline and early follow-up urea, electrolytes and creatinine are standard.

答案

D · Potassium and creatinine
10.内外科护理：心血管与呼吸

答案: B · Magnesium sulfate

为什么是这个答案

A single dose of IV magnesium sulfate is recommended in acute severe or life-threatening asthma that does not respond to initial treatment. Senior and critical care help is called early. Sedatives and beta-blockers are dangerous in acute asthma.

答案

B · Magnesium sulfate
11.内外科护理：神经、内分泌与肾脏

答案: C · Too high harms the kidney; too low risks rejection

为什么是这个答案

Tacrolimus has a narrow therapeutic range and many interactions. High levels can cause nephrotoxicity, tremor and high glucose, while low levels risk rejection. Trough levels are taken before the morning dose.

答案

C · Too high harms the kidney; too low risks rejection
12.内外科护理：神经、内分泌与肾脏

答案: C · Hydrocortisone

为什么是这个答案

Starting thyroid replacement first increases metabolism and cortisol clearance and can trigger an adrenal crisis in a patient with low cortisol. Glucocorticoid replacement is started before levothyroxine.

答案

C · Hydrocortisone
13.内外科护理：消化、围手术期与肿瘤

答案: C · 藻酸盐或泡沫

为什么是这个答案

藻酸盐和泡沫能吸收大量渗出液。水凝胶为干燥伤口增加水分，薄膜适合渗出液少的浅表伤口，干纱布会粘在创面上。应保护周围皮肤免受浸渍。

答案

C · 藻酸盐或泡沫
14.内外科护理：消化、围手术期与肿瘤

答案: D · Oral candidiasis

为什么是这个答案

Oral thrush is common during chemotherapy, especially with steroids or antibiotics. It is reported so that antifungal treatment can be prescribed, and good oral care continues.

答案

D · Oral candidiasis

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