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 had a colostomy formed yesterday. Which stoma appearance should be reported straight away?

  1. AMoist and pink-red
  2. BDark purple or black
  3. CSlightly swollen
  4. DA little bleeding when cleaned
2.优先排序与委派困难

A patient in labor is receiving oxytocin, and the fetal monitor shows repeated late decelerations. What should the nurse do first?

  1. AIncrease the oxytocin rate
  2. BStop the oxytocin infusion
  3. CEncourage the patient to start pushing
  4. DPlace the patient flat on her back
3.感染控制与患者安全中等

哪种敷料废弃物应丢入医疗（生物危害）废物？

  1. A已过期但未开封的敷料
  2. B无菌敷料包的外层纸包装
  3. C被感染伤口渗液浸湿的敷料
  4. D擦手用的干净纸巾
4.感染控制与患者安全困难

During flu season, a nurse wakes up with fever, cough and muscle aches. What is the best action?

  1. AStay home and inform the employer according to the illness policy
  2. BGo to work but wear a surgical mask for the whole shift
  3. CGo to work but avoid caring for patients who have weak immune systems
  4. DTake an antipyretic so the fever does not show at work
5.实验室检查值与电解质中等

一名患者接受皮下注射依诺肝素（一种低分子量肝素）。关于监测，哪项说法是正确的？

  1. A不常规监测 aPTT；而是检查血小板和肾功能
  2. B像华法林一样，用 INR 调整每次剂量
  3. C必须每 6 小时检查 aPTT 来调整剂量
  4. D任何时候都不需要任何血液检查
6.实验室检查值与电解质困难

一名新发深静脉血栓的患者正在使用肝素输注，华法林刚开始使用。为什么肝素要持续使用数日？

  1. A华法林需要数日才能达到完全的抗凝效果
  2. B肝素增加华法林在肠道的吸收
  3. C肝素预防华法林的副作用
  4. D只有同时给予肝素，华法林才起作用
7.临床护理中等

An older adult has left lower abdominal pain, fever and a raised CRP. Which condition is most likely?

  1. ADiverticulitis
  2. BGastric ulcer
  3. CAppendicitis
  4. DBiliary colic
8.临床护理困难

An adult with capacity refuses a blood transfusion for religious reasons, even though it may save their life. What should the nurse do?

  1. ARespect the refusal, check it is informed and document it, and inform the team
  2. BAsk a family member to consent instead
  3. CGive the transfusion while the patient is asleep, as it is in their best interests
  4. DSedate the patient so the transfusion can be given
9.内外科护理：心血管与呼吸中等

How can a patient reduce wound pain when coughing after abdominal surgery?

  1. AHold the breath for as long as possible
  2. BHold a pillow firmly against the wound while coughing
  3. CLie flat on the back with the legs straight
  4. DAvoid coughing completely until all the stitches are removed
10.内外科护理：心血管与呼吸困难

A 74-year-old man with a known abdominal aortic aneurysm suddenly has severe back and abdominal pain. His heart rate is 128/min and BP 82/50 mmHg. What is the priority?

  1. AGive oral analgesia and reassess the pain in an hour
  2. BEncourage him to walk to ease the back pain
  3. CCall for emergency help and prepare for urgent vascular surgery
  4. DArrange a routine outpatient ultrasound scan of the aneurysm
11.内外科护理：神经、内分泌与肾脏中等

脊髓损伤患者发生自主神经反射异常最常见的诱因是什么？

  1. A夜间吃得过快的一顿大餐
  2. B长时间睡眠
  3. C低血糖
  4. D膀胱充盈或导尿管堵塞
12.内外科护理：神经、内分泌与肾脏困难

A patient with a cervical spinal cord injury is helped to sit up for the first time. They become dizzy and pale, and the BP falls from 110/70 to 78/46 mmHg. What should the nurse do?

  1. AGive a large meal and a strong coffee to raise the blood pressure
  2. BStand the patient up to improve the blood flow to the legs
  3. CLower the patient back towards lying, then raise them gradually later
  4. DContinue sitting them upright, because it will pass in an hour
13.内外科护理：消化、围手术期与肿瘤中等

Which wound drain observation should be reported immediately?

  1. AA little dried blood around the drain site
  2. BDrainage slowly falling each day
  3. CSmall amounts of pink serous fluid
  4. DA sudden large volume of fresh red blood
14.内外科护理：消化、围手术期与肿瘤困难

A patient who takes NSAIDs suddenly develops severe epigastric pain, a rigid abdomen and shoulder-tip pain. Which finding would most support the likely diagnosis?

  1. ATall, peaked T waves on a 12-lead ECG
  2. BA raised serum lipase three times the upper limit
  3. CFluid levels in the bladder on an ultrasound scan
  4. DFree air under the diaphragm on an erect chest X-ray

3溶液

1.优先排序与委派

答案: B · Dark purple or black

为什么是这个答案

A healthy stoma is moist and pink to red, and early swelling or slight bleeding is common. A dark purple or black stoma suggests poor blood supply (ischemia) and needs urgent review.

答案

B · Dark purple or black
2.优先排序与委派

答案: B · Stop the oxytocin infusion

为什么是这个答案

Late decelerations point to reduced blood flow through the placenta. Stopping oxytocin reduces contractions; the nurse then turns the patient onto her side, gives IV fluids as prescribed and informs the provider.

答案

B · Stop the oxytocin infusion
3.感染控制与患者安全

答案: C · 被感染伤口渗液浸湿的敷料

为什么是这个答案

被血液或感染性体液污染的物品应依当地规定放入医疗废物。干净的包装放入一般废物或可回收垃圾，使医疗废物量尽可能少。

答案

C · 被感染伤口渗液浸湿的敷料
4.感染控制与患者安全

答案: A · Stay home and inform the employer according to the illness policy

为什么是这个答案

Health care workers with signs of influenza should not work, because they can infect patients and colleagues. They follow the employer’s policy on when they may return.

答案

A · Stay home and inform the employer according to the illness policy
5.实验室检查值与电解质

答案: A · 不常规监测 aPTT；而是检查血小板和肾功能

为什么是这个答案

依诺肝素的效果可预测，因此不用 aPTT 来监测。血小板计数有助于发现肝素诱导的血小板减少症，肾功能也很重要，因为该药经肾脏清除。在妊娠、肥胖或肾病时可使用抗 Xa 水平。

答案

A · 不常规监测 aPTT；而是检查血小板和肾功能
6.实验室检查值与电解质

答案: A · 华法林需要数日才能达到完全的抗凝效果

为什么是这个答案

华法林阻断新的依赖维生素 K 的凝血因子的合成，但现有的因子可持续数日。因此肝素要重叠使用，直到 INR 在目标范围内，通常至少 24 小时，并且至少约 5 天之后。

答案

A · 华法林需要数日才能达到完全的抗凝效果
7.临床护理

答案: A · Diverticulitis

为什么是这个答案

Diverticulitis is inflammation of diverticula, usually in the sigmoid colon, so pain is typically in the left iliac fossa. It is common in older adults.

答案

A · Diverticulitis
8.临床护理

答案: A · Respect the refusal, check it is informed and document it, and inform the team

为什么是这个答案

An adult with capacity has the right to refuse treatment, even life-saving treatment. The team should make sure the patient understands the consequences, discuss alternatives such as cell salvage and record the decision.

答案

A · Respect the refusal, check it is informed and document it, and inform the team
9.内外科护理：心血管与呼吸

答案: B · Hold a pillow firmly against the wound while coughing

为什么是这个答案

Splinting the incision with a pillow or folded towel supports the wound, reduces pain and makes effective coughing easier. Combined with good analgesia and deep breathing, this helps clear secretions and prevents atelectasis and pneumonia.

答案

B · Hold a pillow firmly against the wound while coughing
10.内外科护理：心血管与呼吸

答案: C · Call for emergency help and prepare for urgent vascular surgery

为什么是这个答案

Sudden abdominal or back pain with hypotension in a patient with an AAA suggests rupture, which is often fatal without urgent repair. The team is called at once, large-bore IV access and blood are arranged, and the patient goes to theatre. Fluid may be limited so the blood pressure is not pushed high (permissive hypotension), as directed by the team.

答案

C · Call for emergency help and prepare for urgent vascular surgery
11.内外科护理：神经、内分泌与肾脏

答案: D · 膀胱充盈或导尿管堵塞

为什么是这个答案

膀胱膨胀是最常见的诱因，其次是便秘和粪便嵌塞。受压部位、紧身衣物、嵌甲和皮肤损伤是其他诱因。找出并去除诱因是关键治疗。

答案

D · 膀胱充盈或导尿管堵塞
12.内外科护理：神经、内分泌与肾脏

答案: C · Lower the patient back towards lying, then raise them gradually later

为什么是这个答案

Loss of sympathetic tone causes orthostatic hypotension after high spinal injuries. The patient is reclined, and later raised gradually, often with compression stockings, an abdominal binder and sometimes medicines.

答案

C · Lower the patient back towards lying, then raise them gradually later
13.内外科护理：消化、围手术期与肿瘤

答案: D · A sudden large volume of fresh red blood

为什么是这个答案

A sudden increase in bright red drainage suggests active haemorrhage. The nurse checks vital signs and informs the surgical team urgently. Gradually decreasing serosanguinous drainage is expected.

答案

D · A sudden large volume of fresh red blood
14.内外科护理：消化、围手术期与肿瘤

答案: D · Free air under the diaphragm on an erect chest X-ray

为什么是这个答案

A perforated peptic ulcer releases air into the peritoneal cavity, seen under the diaphragm on an erect chest X-ray or on CT. Shoulder-tip pain is referred from diaphragmatic irritation. The patient is kept nil by mouth, resuscitated and referred urgently to surgeons.

答案

D · Free air under the diaphragm on an erect chest X-ray

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