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

一名带有中心静脉导管的患者在拔除导管时突然呼吸急促，伴胸痛，SpO₂ 下降。护士首先做什么？

  1. A用生理盐水冲洗导管以清除任何阻塞
  2. B覆盖穿刺部位，使患者向左侧卧头低位，给氧并呼叫援助
  3. C让患者坐直，迅速拔完导管
  4. D让患者缓慢深呼吸并继续
3.感染控制与患者安全中等

哪位护士不应被分配护理带有密封放射性植入物的患者？

  1. A怀孕的护士
  2. B接受过辐射安全培训的护士
  3. C佩戴剂量计徽章的护士
  4. D在本病区工作了两年的护士
4.感染控制与患者安全困难

给一名有窒息风险的清醒患者口服药物。哪种做法最安全？

  1. A让患者坐直，一次给一片药
  2. B为节省时间一次给完所有药片
  3. C让患者仰卧平躺，使吞咽更容易
  4. D不检查是否允许就把所有药片碾碎
5.实验室检查值与电解质中等

A patient taking phenazopyridine for bladder pain has bright orange urine. What should the nurse know about urine tests?

  1. AThe dye can interfere with dipstick color readings
  2. BThe color shows severe liver failure is present
  3. CThe color proves blood is present in the urine
  4. DThe drug improves the accuracy of all dipsticks
6.实验室检查值与电解质困难

A healthy woman at 10 weeks of pregnancy has a slightly low TSH with a normal free T4 and no symptoms. What is the most likely explanation?

  1. AShe has pituitary failure from the pregnancy
  2. BShe has developed Graves disease in pregnancy
  3. ChCG stimulates the thyroid in early pregnancy
  4. DThe result shows severe primary hypothyroidism
7.临床护理中等

A patient with sickle cell disease is admitted with a painful crisis. What is a key early nursing priority?

  1. ARestricting oral fluids
  2. BApplying cold packs to the painful areas
  3. CGiving prompt, effective analgesia
  4. DDelaying pain relief until a diagnosis is confirmed
8.临床护理困难

一名腹部手术后的患者八小时未排尿，下腹部不适，可触及膀胱。最可能的问题是什么？

  1. A急性尿潴留
  2. B仅仅是脱水
  3. C无尿生成的急性肾损伤
  4. D不伴潴留的尿路感染
9.内外科护理：心血管与呼吸中等

After varicose vein surgery, which advice is usually given?

  1. AStand still for long periods to help the veins heal
  2. BAvoid all walking until the bruising has gone
  3. CWear the compression stockings as advised and walk regularly
  4. DStay in bed for two weeks with the legs hanging down
10.内外科护理：心血管与呼吸困难

Four hours after abdominal surgery, a patient's heart rate has risen from 84 to 122/min and they are restless and pale. BP is still 118/76 mmHg, and the surgical drain is filling with blood. What should the nurse conclude?

  1. AThe patient is stable because the blood pressure is normal
  2. BThe drain is working well, so no action is needed
  3. CEarly haemorrhagic shock is likely, so escalate urgently
  4. DThe tachycardia is from pain and needs only analgesia
11.内外科护理：神经、内分泌与肾脏中等

Which group of problems is typical of primary hyperparathyroidism?

  1. AMuscle cramps, tingling lips and seizures
  2. BHeat intolerance, tremor, weight loss and diarrhoea
  3. CKidney stones, bone pain, abdominal pain and low mood
  4. DHair loss, weight gain and feeling cold
12.内外科护理：神经、内分泌与肾脏困难

After a stroke, a patient suddenly cries or laughs at odd moments. They say they do not feel sad. Which response is most appropriate?

  1. AExplain that this is emotional lability after stroke and help the family understand
  2. BAsk the doctor for a sedative to stop the outbursts
  3. CTell the patient that crying will slow their recovery
  4. DIgnore it, because it shows that the patient is seeking attention from the staff
13.内外科护理：消化、围手术期与肿瘤中等

Why is the Lund and Browder chart preferred to the rule of nines for children?

  1. AIt is used only for burns of the hands
  2. BIt is faster to use than any other method of estimation
  3. CIt counts superficial burns as well
  4. DIt adjusts for body proportions that change with age
14.内外科护理：消化、围手术期与肿瘤困难

On day 5 after hip surgery, a patient suddenly becomes breathless, with sharp chest pain on breathing in, a pulse of 120/min and SpO₂ 89%. What should the nurse suspect and do first?

  1. AAnxiety; give reassurance and repeat the observations in an hour's time
  2. BPulmonary embolism; sit up, give oxygen and call for urgent help
  3. CWound infection; take a wound swab and wait for results
  4. DSimple atelectasis; encourage walking around the ward

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 · 覆盖穿刺部位，使患者向左侧卧头低位，给氧并呼叫援助

为什么是这个答案

拔管时出现这些征象提示空气栓塞。用密闭敷料覆盖部位可阻止更多空气进入，左侧卧头低位有助于将空气困在右心，使其远离肺动脉。随后给氧并紧急求助。

答案

B · 覆盖穿刺部位，使患者向左侧卧头低位，给氧并呼叫援助
3.感染控制与患者安全

答案: A · 怀孕的护士

为什么是这个答案

怀孕的工作人员和访客不应被安排接触带放射性植入物的患者。其他工作人员应限制与患者相处的时间、保持距离、使用屏蔽并佩戴剂量计。

答案

A · 怀孕的护士
4.感染控制与患者安全

答案: A · 让患者坐直，一次给一片药

为什么是这个答案

直立体位和一次给一种药可降低窒息风险。只有在药房确认安全后才可碾碎，因为一些缓释和肠溶制剂碾碎后会有危险。

答案

A · 让患者坐直，一次给一片药
5.实验室检查值与电解质

答案: A · The dye can interfere with dipstick color readings

为什么是这个答案

Phenazopyridine is a urinary analgesic dye that turns urine orange-red. It can interfere with color-based dipstick tests, so the laboratory should be told. The color is harmless, but it can stain contact lenses and clothing.核对依据: Urine - abnormal color · MedlinePlus (NIH) (2025)

答案

A · The dye can interfere with dipstick color readings
6.实验室检查值与电解质

答案: C · hCG stimulates the thyroid in early pregnancy

为什么是这个答案

hCG is structurally similar to TSH and stimulates the thyroid, peaking at the end of the first trimester, so TSH often falls slightly. With a normal free T4 and no symptoms, this is usually physiologic and is interpreted with pregnancy-specific ranges.核对依据: TSH (Thyroid-stimulating hormone) Test · MedlinePlus (NIH) (2024)

答案

C · hCG stimulates the thyroid in early pregnancy
7.临床护理

答案: C · Giving prompt, effective analgesia

为什么是这个答案

A sickle cell crisis needs rapid analgesia, often opioids, within a short target time, plus hydration, oxygen if hypoxic, warmth and monitoring for complications. Cold can trigger more sickling.

答案

C · Giving prompt, effective analgesia
8.临床护理

答案: A · 急性尿潴留

为什么是这个答案

麻醉、阿片类药物和疼痛都可能引起尿潴留。膀胱扫描可确认残余尿量；通常需要导尿。

答案

A · 急性尿潴留
9.内外科护理：心血管与呼吸

答案: C · Wear the compression stockings as advised and walk regularly

为什么是这个答案

After varicose vein treatment, patients are encouraged to walk regularly and wear compression as instructed to reduce bruising, swelling and DVT risk. They avoid standing still or sitting for long periods and elevate the legs when resting.

答案

C · Wear the compression stockings as advised and walk regularly
10.内外科护理：心血管与呼吸

答案: C · Early haemorrhagic shock is likely, so escalate urgently

为什么是这个答案

Rising heart rate, restlessness, pallor and visible bleeding are signs of compensated haemorrhagic shock. Waiting for hypotension delays treatment. The nurse escalates urgently, gives oxygen, ensures IV access and anticipates bloods, fluids or blood products and surgical review.

答案

C · Early haemorrhagic shock is likely, so escalate urgently
11.内外科护理：神经、内分泌与肾脏

答案: C · Kidney stones, bone pain, abdominal pain and low mood

为什么是这个答案

High PTH raises calcium, which can cause kidney stones, bone loss and pain, constipation and abdominal pain, and low mood or confusion ("stones, bones, groans and moans"). Many cases are found on routine blood tests.

答案

C · Kidney stones, bone pain, abdominal pain and low mood
12.内外科护理：神经、内分泌与肾脏

答案: A · Explain that this is emotional lability after stroke and help the family understand

为什么是这个答案

Emotional lability (pseudobulbar affect) is common after stroke: crying or laughter does not match the person's mood. Explaining it, staying calm and gently distracting the patient helps. True depression is also common and should be screened for separately.

答案

A · Explain that this is emotional lability after stroke and help the family understand
13.内外科护理：消化、围手术期与肿瘤

答案: D · It adjusts for body proportions that change with age

为什么是这个答案

The Lund and Browder chart gives different percentages for the head and legs at different ages, so it is more accurate in children and is also widely used in adults.

答案

D · It adjusts for body proportions that change with age
14.内外科护理：消化、围手术期与肿瘤

答案: B · Pulmonary embolism; sit up, give oxygen and call for urgent help

为什么是这个答案

Sudden pleuritic chest pain, breathlessness, tachycardia and hypoxia after surgery strongly suggest PE. The nurse supports breathing with oxygen, escalates urgently and prepares for investigations and anticoagulation.

答案

B · Pulmonary embolism; sit up, give oxygen and call for urgent help

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