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。

新题目返回课程

在打印窗口中选择“另存为 PDF”，即可在设备上保存一份副本。

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

On the first day after abdominal surgery, a patient has a temperature of 37.9 °C and reduced breath sounds at the lung bases. Which nursing action is most helpful?

  1. AGive a cough suppressant so that the incision is not strained
  2. BEncourage deep breathing, coughing and use of the incentive spirometer
  3. CKeep the patient lying flat in bed to rest the incision fully
  4. DRestrict oral fluids so that the lungs do not fill up with extra fluid
2.优先排序与委派困难

护士应首先看哪名儿童？

  1. A一名 RSV 感染的婴儿，有鼻翼扇动、胸壁凹陷和 89% 的 SpO₂
  2. B一名腿上打石膏、要求喝水的学龄儿童
  3. C一名体温 38.4 °C、正在玩玩具的幼儿
  4. D一名哮喘的青少年，呼气峰流速为个人最佳值的 90%
3.感染控制与患者安全中等

An older adult has trouble getting in and out of the bath. Which measures make bathing safer?

  1. AA loose rug beside the tub to stand on
  2. BLocking the bathroom door for privacy
  3. CBath oil to help the person slide in and out
  4. DA shower chair, grab bars and a non-slip mat
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 16/min, alert, systolic BP 105 mmHg, WBC 13,000/mm3
  2. BRespiratory rate 24/min, new confusion, systolic BP 95 mmHg
  3. CRespiratory rate 20/min, alert, systolic BP 110 mmHg, heart rate 110/min
  4. DRespiratory rate 18/min, alert, systolic BP 130 mmHg, temperature 38.5 °C
5.实验室检查值与电解质中等

A patient's potassium is unexpectedly 5.8 mEq/L. The sample was taken after the tourniquet was on for several minutes while the patient pumped their fist. What is the best interpretation?

  1. AThe result may be falsely high and should be repeated with better technique
  2. BTourniquet time affects only the glucose result, not the potassium
  3. CThe result confirms true hyperkalemia and needs no further checking
  4. DFist pumping lowers potassium, so the true level is even higher
6.实验室检查值与电解质困难

A patient has marked generalized edema. Results show heavy proteinuria, serum albumin 1.8 g/dL (18 g/L) and total cholesterol 340 mg/dL (8.8 mmol/L). Which condition fits best?

  1. AAcute pyelonephritis
  2. BNephrotic syndrome
  3. CLiver cirrhosis only
  4. DPrerenal kidney injury
7.临床护理中等

Which factor is most likely to slow wound healing?

  1. ASmoking
  2. BA diet rich in protein
  3. CAdequate fluid intake
  4. DGood blood glucose control
8.临床护理困难

A conscious patient with hypoglycaemia was given fast-acting carbohydrate. On re-check 15 minutes later the blood glucose is 3.6 mmol/L (65 mg/dL). What should the nurse do next?

  1. ATake no action because the level is rising
  2. BGive a dose of subcutaneous insulin
  3. CGive a long-acting carbohydrate snack only and recheck tomorrow
  4. DGive another dose of fast-acting carbohydrate and recheck
9.内外科护理：心血管与呼吸中等

Which history is a contraindication to thrombolysis for a STEMI?

  1. AA previous appendicectomy many years ago
  2. BTreated high blood pressure
  3. CA previous haemorrhagic stroke
  4. DMild asthma controlled with inhalers
10.内外科护理：心血管与呼吸困难

A patient who has had a total laryngectomy becomes breathless and needs oxygen. How should it be given?

  1. AVia a standard face mask over the nose and mouth
  2. BVia a non-rebreather mask over the mouth only
  3. CVia nasal cannula at 2 L/min
  4. DVia a mask or humidified device over the neck stoma
11.内外科护理：神经、内分泌与肾脏中等

一名服用达格列净（一种 SGLT2 抑制剂）的患者呕吐，血酮 4.5 mmol/L，但血糖只有 11 mmol/L。应怀疑什么？

  1. A呕吐引起的低血糖
  2. B正常血糖性糖尿病酮症酸中毒
  3. C高渗高血糖状态
  4. D不需要处理的正常副作用
12.内外科护理：神经、内分泌与肾脏困难

A patient with trigeminal neuralgia has lost weight and has poor oral hygiene. Which plan is most appropriate?

  1. AAdvise very hot drinks to relax the facial nerves
  2. BTell the patient to stop brushing their teeth completely
  3. COffer soft, lukewarm food and advise chewing on the unaffected side
  4. DEncourage hard, crunchy foods to strengthen the jaw muscles
13.内外科护理：消化、围手术期与肿瘤中等

为什么在大手术后最初几天，常优先选择规律（定时）镇痛而不是“按需”给药？

  1. A它免除了白天评估患者疼痛的需要
  2. B它使药物浓度稳定，防止出现剧烈的疼痛高峰
  3. C它允许给予超过每日最大限量的剂量
  4. D它完全预防所有阿片类药物的副作用
14.内外科护理：消化、围手术期与肿瘤困难

一名患者上臂有环形全层烧伤。未来数小时内，最重要的评估是什么？

  1. A手部的血液循环和感觉
  2. B瞳孔大小和对光反应
  3. C每天双眼视力
  4. D肠鸣音和腹围

3溶液

1.优先排序与委派

答案: B · Encourage deep breathing, coughing and use of the incentive spirometer

为什么是这个答案

Reduced basal breath sounds and a mild temperature early after surgery often mean atelectasis. Deep breathing, coughing, incentive spirometry and early mobilization help re-expand the lungs.

答案

B · Encourage deep breathing, coughing and use of the incentive spirometer
2.优先排序与委派

答案: A · 一名 RSV 感染的婴儿，有鼻翼扇动、胸壁凹陷和 89% 的 SpO₂

为什么是这个答案

鼻翼扇动、凹陷和低 SpO₂ 显示呼吸窘迫，婴儿可能迅速恶化。正在玩耍的发热儿童、口渴的儿童以及峰流速接近正常的青少年都是稳定的。

答案

A · 一名 RSV 感染的婴儿，有鼻翼扇动、胸壁凹陷和 89% 的 SpO₂
3.感染控制与患者安全

答案: D · A shower chair, grab bars and a non-slip mat

为什么是这个答案

Shower chairs, grab bars and non-slip surfaces reduce slips and falls. Bath oils make surfaces slippery, and a locked door delays help if the person falls.

答案

D · A shower chair, grab bars and a non-slip mat
4.感染控制与患者安全

答案: B · 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

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

答案: A · The result may be falsely high and should be repeated with better technique

为什么是这个答案

Repeated fist clenching and a long tourniquet time release potassium from muscle and can cause hemolysis, both of which give a falsely high potassium. The patient is assessed and the test is repeated with correct technique; true hyperkalemia must not be missed.核对依据: Potassium Blood Test · MedlinePlus (NIH) (2024); Potassium test · MedlinePlus (NIH) (2025)

答案

A · The result may be falsely high and should be repeated with better technique
6.实验室检查值与电解质

答案: B · Nephrotic syndrome

为什么是这个答案

Nephrotic syndrome is heavy proteinuria with low albumin, edema and high lipids. Low albumin reduces oncotic pressure, causing edema, and the liver increases lipoprotein production. There is also a higher risk of clots and infection.核对依据: Nephrotic syndrome · MedlinePlus (NIH) (2025)

答案

B · Nephrotic syndrome
7.临床护理

答案: A · Smoking

为什么是这个答案

Smoking causes vasoconstriction and reduces tissue oxygen, slowing healing and increasing infection risk. Poor nutrition, diabetes, infection and steroids also impair healing.

答案

A · Smoking
8.临床护理

答案: D · Give another dose of fast-acting carbohydrate and recheck

为什么是这个答案

If blood glucose remains below the threshold (4 mmol/L in UK guidance, 70 mg/dL in US guidance), the fast-acting treatment is repeated. Once it is above the threshold, a longer-acting carbohydrate such as a sandwich or the next meal helps prevent recurrence.

答案

D · Give another dose of fast-acting carbohydrate and recheck
9.内外科护理：心血管与呼吸

答案: C · A previous haemorrhagic stroke

为什么是这个答案

Absolute contraindications include any previous intracranial haemorrhage, recent ischaemic stroke, active internal bleeding, suspected aortic dissection and recent major trauma or surgery. Thrombolysis is used when primary PCI cannot be delivered in time.

答案

C · A previous haemorrhagic stroke
10.内外科护理：心血管与呼吸

答案: D · Via a mask or humidified device over the neck stoma

为什么是这个答案

A total laryngectomy separates the trachea from the upper airway, so the patient breathes only through the neck stoma. Oxygen and any rescue breaths must be given via the stoma. These patients are "neck breathers" and often carry an alert card.

答案

D · Via a mask or humidified device over the neck stoma
11.内外科护理：神经、内分泌与肾脏

答案: B · 正常血糖性糖尿病酮症酸中毒

为什么是这个答案

SGLT2 抑制剂通过增加尿糖排出来降低血糖，因此血糖仅中度升高时也可发生 DKA。任何服用这类药物且感觉不适的患者都应检查酮体，急性疾病期间应停药（病日规则）。

答案

B · 正常血糖性糖尿病酮症酸中毒
12.内外科护理：神经、内分泌与肾脏

答案: C · Offer soft, lukewarm food and advise chewing on the unaffected side

为什么是这个答案

Patients may avoid eating and brushing their teeth because these trigger attacks. Soft, lukewarm food, chewing on the unaffected side, gentle oral care and effective drug treatment help maintain nutrition and hygiene.

答案

C · Offer soft, lukewarm food and advise chewing on the unaffected side
13.内外科护理：消化、围手术期与肿瘤

答案: B · 它使药物浓度稳定，防止出现剧烈的疼痛高峰

为什么是这个答案

可预测的持续性术后疼痛最好用规律的多模式镇痛来管理（例如对乙酰氨基酚，以及安全时加用 NSAID），爆发痛则按需给药。仍需定期评估疼痛和副作用。

答案

B · 它使药物浓度稳定，防止出现剧烈的疼痛高峰
14.内外科护理：消化、围手术期与肿瘤

答案: A · 手部的血液循环和感觉

为什么是这个答案

全层焦痂没有弹性。随着水肿的发展，压力升高，可影响循环（胸部烧伤时则影响呼吸）。定期检查脉搏、颜色、毛细血管再充盈、疼痛和感觉，可及早发现这一问题；可能需要焦痂切开术。

答案

A · 手部的血液循环和感觉

本内容为独立练习材料。ExamProblems 与该考试的主办机构没有隶属关系，也未获其认可，考试名称仅用于描述内容。 NCLEX®, NCLEX-RN® and NCLEX-PN® 是 the National Council of State Boards of Nursing, Inc. (NCSBN) 的商标，该机构与 ExamProblems 无关，不为其背书，也不保证其准确性。

ExamProblems · examproblems.com/courses/nclex-style-prioritization-and-delegation