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 wants to leave the hospital against medical advice. What should the nurse do?

  1. AInform the provider, explain the risks and document the discussion
  2. BHide the patient’s clothes and belongings until the provider arrives
  3. CLock the door so the patient cannot leave the unit
  4. DLet the patient leave without telling anyone
2.优先排序与委派困难

一名头部受伤并伴有腿部骨折的患者正在接受监测。哪项发现是优先事项？

  1. A肘部有一处小擦伤
  2. B患者要求吃点东西
  3. C尽管刚用过镇痛药，腿痛仍为 6/10
  4. D格拉斯哥昏迷评分从 15 分降至 12 分
3.感染控制与患者安全中等

A patient wants to use their own electric hair dryer in the hospital. What is correct?

  1. AIt can be used straight away if it looks new
  2. BIt can be used in the bathroom near the sink if the patient is careful
  3. CIt can be plugged into an extension lead under the bed
  4. DIt is checked for electrical safety according to hospital policy before use
4.感染控制与患者安全困难

A nurse teaches a patient with neutropenia about preventing infection at home. Which statement shows a need for further teaching?

  1. A“I can clean the cat’s litter box if I wear a face mask.”
  2. B“I will check my temperature and call if I have a fever.”
  3. C“I will wash my hands often and ask visitors to do the same.”
  4. D“I will avoid crowds and people who have colds.”
5.实验室检查值与电解质中等

A patient with type 2 diabetes starts prednisone each morning. When is the glucose most likely to be highest?

  1. AThe glucose will not change
  2. BAt midnight only
  3. CIn the afternoon and evening
  4. DIn the early morning, before the dose
6.实验室检查值与电解质困难

一名患者在大量呕血 30 分钟后到达。心率 125 次/分，但首次血红蛋白为 13.0 g/dL（130 g/L）。为什么血红蛋白具有误导性？

  1. A出血时血红蛋白升高，掩盖了失血
  2. B丢失的是全血，所以浓度数小时后才会下降
  3. C该数值证明没有明显出血
  4. D该检测在紧急情况下从不准确
7.临床护理中等

Which finding with a groin hernia needs urgent surgical review?

  1. AThe lump disappears completely when the patient lies down flat
  2. BThe lump gets bigger when the patient coughs
  3. CThe lump has been present for several years without pain
  4. DThe lump has become painful and tender and cannot be pushed back
8.临床护理困难

A patient has a single hot, swollen, very painful knee and a fever. Why is urgent joint aspiration important?

  1. ATo measure the patient's cholesterol
  2. BTo prevent osteoporosis
  3. CTo rule out septic arthritis, which can rapidly destroy the joint
  4. DTo check for rheumatoid arthritis antibodies in the joint fluid
9.内外科护理：心血管与呼吸中等

After a bronchoscopy with throat anaesthesia, when can the patient eat and drink?

  1. AWhen the gag and cough reflexes have returned
  2. BOnly after a chest X-ray has been reported
  3. CImmediately after the scope is removed
  4. DAfter a full 24 hours without food
10.内外科护理：心血管与呼吸困难

Which method best confirms that an endotracheal tube is in the trachea?

  1. AThe patient's skin colour improving
  2. BMisting inside the tube
  3. CThe chest rising on one side only
  4. DA sustained waveform on capnography
11.内外科护理：神经、内分泌与肾脏中等

For which patient with migraine would the nurse question an order for sumatriptan?

  1. AA patient with a history of angina
  2. BA patient with well-controlled hypothyroidism
  3. CA patient who also has asthma
  4. DA patient with an allergy to penicillin
12.内外科护理：神经、内分泌与肾脏困难

A patient with long-standing diabetes suddenly has many new floaters and painless loss of vision in one eye. What is most likely, and what is needed?

  1. ANormal ageing of the lens, needing new glasses
  2. BA bleed into the eye from retinopathy, needing urgent review
  3. CA migraine aura, needing pain relief
  4. DDry eyes, needing lubricating drops
13.内外科护理：消化、围手术期与肿瘤中等

Why is it important to prevent perioperative hypothermia?

  1. AIt reduces the amount of anaesthetic needed, which is unsafe
  2. BIt makes patients wake up from the anaesthetic too quickly
  3. CIt lowers the risk of pain after surgery
  4. DIt increases bleeding, wound infection and heart complications
14.内外科护理：消化、围手术期与肿瘤困难

一名肠梗阻患者出现持续剧烈疼痛（不再是绞痛）、发热、心率 120 次/分，以及腹部强直、压痛。这提示什么？

  1. A便秘，应使用刺激性泻药治疗
  2. B正常进展，只需规律的简单镇痛
  3. C梗阻正在缓解，肠道开始蠕动
  4. D绞窄或穿孔，需要紧急外科评估

3溶液

1.优先排序与委派

答案: A · Inform the provider, explain the risks and document the discussion

为什么是这个答案

A competent adult has the right to leave. The nurse informs the provider, makes sure the patient understands the risks and documents it; holding the patient against their will may be false imprisonment.

答案

A · Inform the provider, explain the risks and document the discussion
2.优先排序与委派

答案: D · 格拉斯哥昏迷评分从 15 分降至 12 分

为什么是这个答案

GCS 下降提示颅内压升高，可能致命，需要紧急上报。骨折疼痛也需要处理，但不像这样威胁生命。

答案

D · 格拉斯哥昏迷评分从 15 分降至 12 分
3.感染控制与患者安全

答案: D · It is checked for electrical safety according to hospital policy before use

为什么是这个答案

Electrical items from home can be faulty and cause shocks or fires. Policies usually require them to be inspected before use, and extension cords near patients are avoided.

答案

D · It is checked for electrical safety according to hospital policy before use
4.感染控制与患者安全

答案: A · “I can clean the cat’s litter box if I wear a face mask.”

为什么是这个答案

Immunocompromised patients should avoid cleaning litter boxes and other animal waste, because of organisms such as Toxoplasma. Another person should do it. The other statements are correct.

答案

A · “I can clean the cat’s litter box if I wear a face mask.”
5.实验室检查值与电解质

答案: C · In the afternoon and evening

为什么是这个答案

A morning dose of prednisone raises glucose mainly in the afternoon and evening, with a smaller effect overnight. Glucose monitoring and insulin plans often target these times, and doses are adjusted when the steroid is tapered.核对依据: Blood Glucose Test · MedlinePlus (NIH) (2024)

答案

C · In the afternoon and evening
6.实验室检查值与电解质

答案: B · 丢失的是全血，所以浓度数小时后才会下降

为什么是这个答案

出血早期，红细胞和血浆一起丢失，因此浓度起初保持正常。在最初几小时，心率和血压是判断失血更好的指标。

答案

B · 丢失的是全血，所以浓度数小时后才会下降
7.临床护理

答案: D · The lump has become painful and tender and cannot be pushed back

为什么是这个答案

An irreducible, painful, tender hernia, especially with vomiting, suggests incarceration or strangulation. This is a surgical emergency because the trapped bowel can become ischaemic.

答案

D · The lump has become painful and tender and cannot be pushed back
8.临床护理

答案: C · To rule out septic arthritis, which can rapidly destroy the joint

为什么是这个答案

Septic arthritis can destroy cartilage within days. Aspiration allows microscopy and culture, and helps distinguish infection from crystal arthritis such as gout.

答案

C · To rule out septic arthritis, which can rapidly destroy the joint
9.内外科护理：心血管与呼吸

答案: A · When the gag and cough reflexes have returned

为什么是这个答案

Local anaesthetic sprayed on the throat abolishes the gag and cough reflexes for a time, so food or fluid could be aspirated. The nurse checks that the reflexes have returned (often after about one to two hours) before giving sips of water and then food.

答案

A · When the gag and cough reflexes have returned
10.内外科护理：心血管与呼吸

答案: D · A sustained waveform on capnography

为什么是这个答案

A sustained exhaled carbon dioxide waveform confirms tracheal placement. Misting and chest movement can be misleading, and skin colour changes late. A chest X-ray shows the depth of the tube but does not prove it is in the trachea.

答案

D · A sustained waveform on capnography
11.内外科护理：神经、内分泌与肾脏

答案: A · A patient with a history of angina

为什么是这个答案

Triptans constrict blood vessels, including the coronary arteries. They are contraindicated in coronary artery disease, previous stroke and uncontrolled hypertension.

答案

A · A patient with a history of angina
12.内外科护理：神经、内分泌与肾脏

答案: B · A bleed into the eye from retinopathy, needing urgent review

为什么是这个答案

Proliferative diabetic retinopathy causes fragile new blood vessels that can bleed into the vitreous, causing sudden floaters or vision loss. It needs same-day or urgent ophthalmology review. Retinal detachment is also possible.

答案

B · A bleed into the eye from retinopathy, needing urgent review
13.内外科护理：消化、围手术期与肿瘤

答案: D · It increases bleeding, wound infection and heart complications

为什么是这个答案

Even mild hypothermia impairs clotting, increases surgical site infection and cardiac events, and causes shivering and discomfort. Forced-air warming, warmed fluids and covering the patient help prevent it.

答案

D · It increases bleeding, wound infection and heart complications
14.内外科护理：消化、围手术期与肿瘤

答案: D · 绞窄或穿孔，需要紧急外科评估

为什么是这个答案

疼痛从绞痛变为持续性疼痛，伴发热、心动过速、腹膜刺激征或乳酸升高，提示缺血（绞窄）或穿孔。这是外科急症。机械性梗阻禁用泻药。

答案

D · 绞窄或穿孔，需要紧急外科评估

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