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

哪项陈述表明对委派中的问责有正确理解？

  1. A“护理助理要对该任务是否适合委派负责。”
  2. B“我对决定委派以及跟进结果负有问责。”
  3. C“如果任务出了问题，只有助理负责。”
  4. D“一旦我委派了任务，就与我无关了。”
2.优先排序与委派困难

A patient at 36 weeks of pregnancy has sudden severe abdominal pain, a hard, board-like uterus and dark vaginal bleeding. What should the nurse suspect?

  1. ANormal labor contractions starting
  2. BPlacental abruption, which is an emergency
  3. CPlacenta previa, which is usually painless
  4. DA urinary tract infection
3.感染控制与患者安全中等

A patient in bed has a generalized tonic-clonic seizure. What should the nurse do?

  1. AHold the arms and legs firmly to stop the movements
  2. BPut a padded tongue blade between the teeth to protect the tongue from biting
  3. CGive sips of water to keep the airway moist
  4. DTurn the patient on their side and protect them from injury without restraining
4.感染控制与患者安全困难

两种不同药物的外观相似药瓶并排存放，一名护士差点拿错。下列哪种应对最体现公正文化？

  1. A上报并改进系统，例如把药瓶分开存放
  2. B告诉护士要更加小心，不做其他处理
  3. C为维护病区声誉而隐瞒此事
  4. D处分差点拿错药瓶的护士
5.实验室检查值与电解质中等

A nurse completed the hepatitis B vaccine series. Which result shows protective immunity?

  1. AAnti-HBs of 10 mIU/mL or more
  2. BA positive IgM anti-HBc
  3. CA raised ALT level
  4. DA positive HBsAg test
6.实验室检查值与电解质困难

A patient with acute pancreatitis has a rising BUN, a falling calcium and a glucose of 250 mg/dL (13.9 mmol/L) over the first 48 hours. What do these results suggest?

  1. AAn unrelated new kidney stone
  2. BA resolving, mild pancreatitis
  3. CIncreasingly severe pancreatitis
  4. DA lab error from lipemic samples
7.临床护理中等

In suspected sepsis, what should ideally be collected before the first dose of antibiotics, as long as it does not delay treatment?

  1. AA stool sample for occult blood
  2. BA 24-hour urine collection
  3. CA fasting cholesterol level
  4. DBlood cultures
8.临床护理困难

一名头部外伤患者出现血压升高、心率减慢和呼吸不规则。这提示：

  1. A颅内压增高（库欣三联征）
  2. B脓毒症
  3. C惊恐发作
  4. D隐匿性内出血引起的低血容量性休克
9.内外科护理：心血管与呼吸中等

What is the purpose of a mucolytic such as carbocisteine in chronic productive cough?

  1. ATo stop the patient coughing completely, day and night
  2. BTo kill bacteria in the airways
  3. CTo make sputum thinner and easier to cough up
  4. DTo widen the airways within minutes
10.内外科护理：心血管与呼吸困难

A patient with severe asthma develops a stable narrow-complex tachycardia, and IV adenosine is prescribed. What should the nurse do?

  1. AGive it orally instead of intravenously
  2. BQuestion the prescription, as adenosine can cause bronchospasm
  3. CGive it as a slow infusion over an hour to reduce side effects
  4. DGive it as prescribed, as adenosine is safe in every patient
11.内外科护理：神经、内分泌与肾脏中等

甲状腺切除术后，为什么常在床边备有拆线或拆夹器？

  1. A用于从颈静脉抽血
  2. B用于在引流管不通时调整引流管
  3. C必须在术后第一天晚上拆线
  4. D颈部血肿可压迫气道，可能需要松解
12.内外科护理：神经、内分泌与肾脏困难

On the first day after a kidney transplant, urine output suddenly falls from 200 mL/h to 10 mL/h. What should the nurse check first?

  1. AThe patient's blood glucose level
  2. BThe patient's temperature and pulse
  3. CThat the catheter is not blocked or kinked
  4. DWhether the patient has eaten
13.内外科护理：消化、围手术期与肿瘤中等

Which statement about pain in older adults is correct?

  1. AOpioids must never be used in people over 70
  2. BPain is a normal part of ageing and does not need any treatment at all
  3. COlder adults feel less pain because nerves wear out
  4. DThey may under-report pain, so active assessment is needed
14.内外科护理：消化、围手术期与肿瘤困难

During radiotherapy to the chest, a patient develops pain on swallowing and is eating less. What is the most likely cause and nursing focus?

  1. ANormal ageing; no action needed
  2. BRadiation oesophagitis; analgesia, soft food and nutrition support
  3. CA stomach ulcer; give an antacid after meals only
  4. DA heart attack; give aspirin and arrange an ECG

3溶液

1.优先排序与委派

答案: B · “我对决定委派以及跟进结果负有问责。”

为什么是这个答案

委派的护士对委派这一决定以及监督和评价负有问责。被委派者负责在其能力范围内正确地执行任务。

答案

B · “我对决定委派以及跟进结果负有问责。”
2.优先排序与委派

答案: B · Placental abruption, which is an emergency

为什么是这个答案

Painful bleeding with a rigid, tender uterus suggests placental abruption, where the placenta separates early. Mother and baby are at risk, so urgent escalation and monitoring are needed.

答案

B · Placental abruption, which is an emergency
3.感染控制与患者安全

答案: D · Turn the patient on their side and protect them from injury without restraining

为什么是这个答案

The nurse stays with the patient, turns them to the side to keep the airway clear, moves hard objects away and times the seizure. Objects in the mouth and restraint can cause injury.

答案

D · Turn the patient on their side and protect them from injury without restraining
4.感染控制与患者安全

答案: A · 上报并改进系统，例如把药瓶分开存放

为什么是这个答案

公正文化认识到人为失误往往源于系统设计。把外观相似的药物分开存放、使用标签和 Tall Man 大写标注可防止再次发生。只责怪个人而不处理隐患，危险依然存在。

答案

A · 上报并改进系统，例如把药瓶分开存放
5.实验室检查值与电解质

答案: A · Anti-HBs of 10 mIU/mL or more

为什么是这个答案

An anti-HBs level of at least 10 mIU/mL after vaccination indicates protection. HBsAg and IgM anti-HBc indicate infection, not immunity. Health care workers are often tested after vaccination.

答案

A · Anti-HBs of 10 mIU/mL or more
6.实验室检查值与电解质

答案: C · Increasingly severe pancreatitis

为什么是这个答案

Rising BUN (fluid loss and kidney injury), low calcium and hyperglycemia are markers of more severe pancreatitis in scoring systems. The nurse monitors fluid balance, vital signs and organ function closely and reports deterioration.

答案

C · Increasingly severe pancreatitis
7.临床护理

答案: D · Blood cultures

为什么是这个答案

Blood cultures taken before antibiotics are more likely to grow the organism, which allows targeted treatment later. Antibiotics should still be given promptly and must not be delayed.

答案

D · Blood cultures
8.临床护理

答案: A · 颅内压增高（库欣三联征）

为什么是这个答案

库欣三联征（高血压伴脉压增大、心动过缓和呼吸不规则）是颅内压增高的晚期征象，需要紧急处理。

答案

A · 颅内压增高（库欣三联征）
9.内外科护理：心血管与呼吸

答案: C · To make sputum thinner and easier to cough up

为什么是这个答案

Mucolytics reduce sputum viscosity, which can make expectoration easier and may reduce exacerbations in some people with COPD. They are not bronchodilators or antibiotics. Cough suppressants are generally avoided in productive cough.

答案

C · To make sputum thinner and easier to cough up
10.内外科护理：心血管与呼吸

答案: B · Question the prescription, as adenosine can cause bronchospasm

为什么是这个答案

Adenosine can trigger severe bronchospasm and is generally avoided in asthma. Alternatives such as verapamil may be used, depending on the patient. The nurse raises the concern with the prescriber before giving it.

答案

B · Question the prescription, as adenosine can cause bronchospasm
11.内外科护理：神经、内分泌与肾脏

答案: D · 颈部血肿可压迫气道，可能需要松解

为什么是这个答案

甲状腺手术后颈部血肿可迅速压迫气道。许多病房在床边备有拆夹器或拆线器及气道设备，以便在紧急情况下打开伤口。护士应观察有无肿胀、喘鸣和呼吸困难。

答案

D · 颈部血肿可压迫气道，可能需要松解
12.内外科护理：神经、内分泌与肾脏

答案: C · That the catheter is not blocked or kinked

为什么是这个答案

A sudden drop in output after transplant may be caused by a blocked catheter, often from clots. The nurse checks the tubing and may flush the catheter per protocol, and then escalates urgently, because vascular thrombosis or rejection are also possible.

答案

C · That the catheter is not blocked or kinked
13.内外科护理：消化、围手术期与肿瘤

答案: D · They may under-report pain, so active assessment is needed

为什么是这个答案

Older adults may minimise pain or have cognitive or sensory problems that hinder reporting. Regular assessment with suitable tools and careful analgesia, starting low and adjusting slowly, are recommended.

答案

D · They may under-report pain, so active assessment is needed
14.内外科护理：消化、围手术期与肿瘤

答案: B · Radiation oesophagitis; analgesia, soft food and nutrition support

为什么是这个答案

Radiotherapy to the chest can inflame the oesophagus, causing painful swallowing. Analgesia (sometimes before meals), soft moist food, nutritional supplements, dietitian input and monitoring weight are important.

答案

B · Radiation oesophagitis; analgesia, soft food and nutrition support

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