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 conscious patient with hypoglycemia drank juice 15 minutes ago. The glucose is now 62 mg/dL (3.4 mmol/L). What should the nurse do next?

  1. ARecord the result and recheck the glucose at the usual time before the evening meal
  2. BGive another serving of fast-acting carbohydrate and recheck in 15 minutes
  3. CGive the next scheduled dose of rapid-acting insulin with the meal
  4. DWait another hour, because juice can take a long time to work
2.优先排序与委派困难

An older patient with heart failure is receiving a second unit of blood. She becomes breathless, with crackles in both lungs and a rising blood pressure. What is most likely happening?

  1. AAn expected effect of the first unit
  2. BA mild allergic reaction with hives
  3. CTransfusion-associated circulatory overload
  4. DHypoglycemia caused by the stored blood product
3.感染控制与患者安全中等

“Tall Man”大写字母标注法（如 hydrOXYzine 和 hydrALAZINE）的目的是什么？

  1. A表明两种药物中哪一种是高警示药物
  2. B表示药物的规格
  3. C使外观相似的药名更容易区分
  4. D表示商品名
4.感染控制与患者安全困难

Which patient with a suspected infection meets the qSOFA criteria that signal a higher risk of a poor outcome?

  1. ARespiratory rate 24/min, new confusion, systolic BP 95 mmHg
  2. BRespiratory rate 16/min, alert, systolic BP 105 mmHg, WBC 13,000/mm3
  3. CRespiratory rate 18/min, alert, systolic BP 130 mmHg, temperature 38.5 °C
  4. DRespiratory rate 20/min, alert, systolic BP 110 mmHg, heart rate 110/min
5.实验室检查值与电解质中等

A patient on warfarin has an INR of 7.8 and a nosebleed. Which medication would the nurse expect the provider to prescribe?

  1. AProtamine sulfate
  2. BAcetylcysteine
  3. CVitamin K (phytonadione)
  4. DNaloxone hydrochloride
6.实验室检查值与电解质困难

The nurse prepares a patient for a 2-hour oral glucose tolerance test tomorrow morning. Which statement shows a need for further teaching?

  1. A"I'll stay seated during the test if I can"
  2. B"I'll avoid smoking until the test is over"
  3. C"I can have a light breakfast before the test"
  4. D"I'll fast overnight but can drink plain water"
7.临床护理中等

A patient is having a 12-lead ECG. Where are the chest electrodes placed?

  1. AAnywhere on the chest where the skin is clear
  2. BIn a straight line down the centre of the sternum from top to bottom
  3. CIn standard numbered positions across the front and left of the chest
  4. DOn both shoulders and both hips only
8.临床护理困难

Several hours after thyroid surgery, a patient has increasing neck swelling, stridor and difficulty breathing. What is most likely?

  1. AA haematoma compressing the airway
  2. BNormal postoperative swelling
  3. CA thyroid storm
  4. DHypocalcaemia from parathyroid damage
9.内外科护理：心血管与呼吸中等

Why is a raised serum lactate concerning in a patient with shock?

  1. AIt means the kidneys are working harder than normal to clear fluid
  2. BIt confirms a bacterial infection is present
  3. CIt shows only that the patient has eaten a large meal in the past hour
  4. DIt suggests tissues are short of oxygen and using anaerobic metabolism
10.内外科护理：心血管与呼吸困难

一名二尖瓣机械瓣置换术后服用华法林的患者 INR 为 2.2。护士应考虑什么？

  1. AINR 高到危险程度，必须暂停用药
  2. BINR 在所有华法林适应证的范围内，所以无需处理
  3. C机械瓣的 INR 应在约 1.0
  4. DINR 可能低于该患者较高的目标值，应核查并上报
11.内外科护理：神经、内分泌与肾脏中等

A nurse is teaching a patient going home after a mild concussion. Which statement shows a need for further teaching?

  1. A"I will come back if I start vomiting again and again."
  2. B"A few drinks tonight will help me relax and sleep."
  3. C"I will return if my headache gets steadily worse."
  4. D"Someone will stay with me for the first night."
12.内外科护理：神经、内分泌与肾脏困难

一名护士正在护理四位患者。应首先看哪位患者？

  1. A到了服用左甲状腺素时间的稳定型甲状腺功能减退患者
  2. B询问磷结合剂的 CKD 患者
  3. C流出液清亮的腹膜透析患者
  4. D开颅术后右侧瞳孔新近散大且反应迟钝的患者
13.内外科护理：消化、围手术期与肿瘤中等

Which nerve is at risk if the arm is poorly padded at the elbow during surgery?

  1. AUlnar nerve
  2. BFacial nerve
  3. CFemoral nerve
  4. DSciatic nerve
14.内外科护理：消化、围手术期与肿瘤困难

On the morning of elective hip surgery, a patient says she took her usual warfarin last night despite being told to stop. What should the nurse do?

  1. AProceed with the usual checklist and say nothing
  2. BTell her the surgery must be cancelled for a month
  3. CGive a double dose of vitamin K by mouth without waiting for a prescription
  4. DInform the surgical and anaesthetic teams, who will check the INR

3溶液

1.优先排序与委派

答案: B · Give another serving of fast-acting carbohydrate and recheck in 15 minutes

为什么是这个答案

If the glucose is still below the hypoglycemia threshold after treatment (70 mg/dL in US guidance, 4.0 mmol/L in UK guidance), the fast-acting carbohydrate is repeated and the glucose rechecked. Once it is normal, a snack or meal helps keep it stable.

答案

B · Give another serving of fast-acting carbohydrate and recheck in 15 minutes
2.优先排序与委派

答案: C · Transfusion-associated circulatory overload

为什么是这个答案

Breathlessness, crackles and hypertension during a transfusion in a patient with heart failure suggest circulatory overload. The nurse stops the transfusion, sits the patient up, gives oxygen as prescribed and informs the provider, who may prescribe a diuretic.

答案

C · Transfusion-associated circulatory overload
3.感染控制与患者安全

答案: C · 使外观相似的药名更容易区分

为什么是这个答案

Tall Man 标注法把相似药名中不同的字母用大写表示，使工作人员在阅读标签、屏幕和医嘱时能注意到差异。

答案

C · 使外观相似的药名更容易区分
4.感染控制与患者安全

答案: A · Respiratory rate 24/min, new confusion, systolic BP 95 mmHg

为什么是这个答案

qSOFA scores one point each for a respiratory rate of 22/min or more, altered mental status and a systolic BP of 100 mmHg or less. Two or more points mean higher risk, so the first patient needs urgent escalation.

答案

A · Respiratory rate 24/min, new confusion, systolic BP 95 mmHg
5.实验室检查值与电解质

答案: C · Vitamin K (phytonadione)

为什么是这个答案

Warfarin blocks vitamin K–dependent clotting factors, and vitamin K restores their production over hours. For serious bleeding, a prothrombin complex concentrate may also be given to replace factors at once. The warfarin is held.核对依据: Label: WARFARIN SODIUM tablet · DailyMed (NLM/FDA) (2012)

答案

C · Vitamin K (phytonadione)
6.实验室检查值与电解质

答案: C · "I can have a light breakfast before the test"

为什么是这个答案

The OGTT is done after an overnight fast of at least 8 hours; water is allowed. Eating before the test makes the results invalid. Patients rest during the test and avoid smoking, which can affect glucose.核对依据: Blood Glucose Test · MedlinePlus (NIH) (2024); Glucose tolerance test - non-pregnant · MedlinePlus (NIH) (2025)

答案

C · "I can have a light breakfast before the test"
7.临床护理

答案: C · In standard numbered positions across the front and left of the chest

为什么是这个答案

The six chest leads (V1–V6) have standard anatomical positions, from the 4th intercostal space beside the sternum to the mid-axillary line. Wrong placement can change the ECG and lead to misinterpretation.

答案

C · In standard numbered positions across the front and left of the chest
8.临床护理

答案: A · A haematoma compressing the airway

为什么是这个答案

A rapidly expanding neck haematoma after thyroid surgery is an airway emergency. Call for urgent help; local protocols often require equipment to release the wound clips or sutures to be kept at the bedside.

答案

A · A haematoma compressing the airway
9.内外科护理：心血管与呼吸

答案: D · It suggests tissues are short of oxygen and using anaerobic metabolism

为什么是这个答案

When tissues are poorly perfused, cells switch to anaerobic metabolism and produce lactate. A raised lactate is a marker of tissue hypoperfusion and severity in sepsis and shock. Repeated measurements show whether treatment is working.

答案

D · It suggests tissues are short of oxygen and using anaerobic metabolism
10.内外科护理：心血管与呼吸

答案: D · INR 可能低于该患者较高的目标值，应核查并上报

为什么是这个答案

机械心脏瓣膜，尤其是二尖瓣位置，通常需要更高的 INR 目标（例如 2.5–3.5，取决于瓣膜类型和危险因素）。INR 2.2 可能未达治疗水平，增加瓣膜血栓和卒中的风险。护士应核对记录的目标值并通知开处方者。机械瓣不使用 DOAC。

答案

D · INR 可能低于该患者较高的目标值，应核查并上报
11.内外科护理：神经、内分泌与肾脏

答案: B · "A few drinks tonight will help me relax and sleep."

为什么是这个答案

After a head injury, alcohol and sedatives should be avoided because they can mask drowsiness and confusion. A responsible adult should stay with the patient, and worsening headache, repeated vomiting, confusion or drowsiness mean they must return.

答案

B · "A few drinks tonight will help me relax and sleep."
12.内外科护理：神经、内分泌与肾脏

答案: D · 开颅术后右侧瞳孔新近散大且反应迟钝的患者

为什么是这个答案

脑部手术后新出现的单侧瞳孔散大且反应迟钝，提示颅内压升高压迫动眼神经，是可能脑疝的征象。需要立即评估，包括 GCS 和生命体征，并紧急上报。其他患者情况稳定，他们的需求可稍后满足。

答案

D · 开颅术后右侧瞳孔新近散大且反应迟钝的患者
13.内外科护理：消化、围手术期与肿瘤

答案: A · Ulnar nerve

为什么是这个答案

The ulnar nerve runs superficially at the elbow and is a common site of positioning injury. Careful padding and avoiding pressure on the elbow help prevent numbness and weakness of the hand.

答案

A · Ulnar nerve
14.内外科护理：消化、围手术期与肿瘤

答案: D · Inform the surgical and anaesthetic teams, who will check the INR

为什么是这个答案

Recent warfarin may leave the INR too high for safe surgery or a spinal anaesthetic. The team needs to know at once; they check the INR and decide whether to delay or reverse.

答案

D · Inform the surgical and anaesthetic teams, who will check the INR

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