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

Before accessing a central venous catheter, what should the nurse do to prevent infection?

  1. ABlow on the hub to remove any dust before connecting the syringe or line
  2. BScrub the hub with an antiseptic such as chlorhexidine and let it dry
  3. CTouch the hub to check it is clean
  4. DRinse the hub with tap water and dry it
2.优先排序与委派困难

A patient with diabetic ketoacidosis is about to start an IV insulin infusion. The serum potassium is 3.0 mEq/L. What should the nurse do?

  1. AReport the result before starting, because insulin will push potassium even lower
  2. BGive the insulin as a fast bolus to bring the potassium up
  3. CIgnore the result, since potassium is always high in this condition and will correct itself
  4. DStart the insulin at once, because the glucose is the bigger problem
3.感染控制与患者安全中等

A nurse’s hands are dry and cracked from frequent hand hygiene. What is the best approach?

  1. AStop hand hygiene until the skin heals
  2. BWear gloves all day instead of cleaning the hands between patients
  3. CUse any lotion from home, whatever its contents
  4. DUse the hand lotion approved by the facility to keep the skin intact
4.感染控制与患者安全困难

A nurse has just started a unit of red blood cells when a colleague asks for urgent help with another patient. What is the best action?

  1. ALeave to help the other patient, and check the transfusion again in about an hour
  2. BStay with the transfusing patient for the first 15 minutes and ask another nurse to help
  3. CPause the transfusion until the nurse is free again
  4. DSpeed up the transfusion so it finishes sooner
5.实验室检查值与电解质中等

垂体手术后，一名患者每小时排出约 400 mL 淡色尿，比重 1.002，钠已升至 149 mEq/L。最可能的是哪种情况？

  1. A尿崩症
  2. BSIADH
  3. C高血糖伴酮症酸中毒
  4. D急性肾损伤伴少尿
6.实验室检查值与电解质困难

哪种结果模式符合 SIADH？

  1. A血清钠低、血清渗透压高、尿液稀
  2. B血清钠高、血清渗透压高、尿液非常稀
  3. C钠正常，尿液非常稀
  4. D血清钠低、血清渗透压低、尿液浓缩
7.临床护理中等

一名患者有绞痛样腹痛、腹胀、呕吐，两天未排便排气。可能的问题是什么？

  1. A无并发症的阑尾炎
  2. B胃肠炎
  3. C肠易激综合征
  4. D肠梗阻
8.临床护理困难

一名留置中心静脉导管的患者在坐位断开导管时，突然出现气短和低血压。最可能是哪种并发症？

  1. A低血糖
  2. B静脉炎
  3. C空气栓塞
  4. D肺炎
9.内外科护理：心血管与呼吸中等

A patient with angle-closure glaucoma needs nebulised ipratropium. What precaution is sensible?

  1. ARun it at the highest possible gas flow
  2. BUse a mouthpiece or protect the eyes from the mist
  3. CGive it only with the patient lying completely flat
  4. DMix it with an eye drop before putting it in the nebuliser
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. AMisting inside the tube
  2. BThe patient's skin colour improving
  3. CA sustained waveform on capnography
  4. DThe chest rising on one side only
11.内外科护理：神经、内分泌与肾脏中等

为什么在 DKA 静脉输注胰岛素时必须密切监测钾？

  1. A胰岛素使钾进入细胞，因此血钾可能迅速下降
  2. B胰岛素使肾脏潴留钾，因此血钾会上升
  3. C胰岛素在血液中分解钾
  4. D在 DKA 中胰岛素对钾没有影响
12.内外科护理：神经、内分泌与肾脏困难

A kidney transplant recipient has had vomiting and diarrhoea for two days. Why should the transplant team be contacted?

  1. AVomiting proves that rejection has already happened
  2. BThe kidney will start to produce far too much urine
  3. CThe patient may not be absorbing their immunosuppressants
  4. DThe tablets will make the vomiting stop
13.内外科护理：消化、围手术期与肿瘤中等

Why should metoclopramide not be used for nausea in mechanical bowel obstruction?

  1. AIt always causes severe diarrhoea
  2. BIt blocks the effect of all opioids
  3. CIt increases gut movement against the blockage
  4. DIt makes the bowel stop moving completely
14.内外科护理：消化、围手术期与肿瘤困难

On day 3 after surgery, a patient has a temperature of 38.6 °C, respiratory rate 24/min, pulse 118/min, BP 92/58 mmHg and new confusion. What should the nurse do?

  1. AEscalate urgently and start the sepsis pathway
  2. BEncourage oral fluids and wait for the doctor's round
  3. CGive paracetamol and recheck in four hours
  4. DRecord the observations and continue routine care

3溶液

1.优先排序与委派

答案: B · Scrub the hub with an antiseptic such as chlorhexidine and let it dry

为什么是这个答案

Scrubbing the needleless connector with an antiseptic, such as chlorhexidine or alcohol, and letting it dry reduces central line infections. Aseptic technique is used for every access.

答案

B · Scrub the hub with an antiseptic such as chlorhexidine and let it dry
2.优先排序与委派

答案: A · Report the result before starting, because insulin will push potassium even lower

为什么是这个答案

Insulin drives potassium into cells and can cause dangerous hypokalemia, so a low starting potassium must be reported. US (ADA) guidance delays insulin until potassium is at least 3.3 mEq/L; UK (JBDS) guidance asks for urgent senior review and potassium replacement. Either way, the prescriber decides.

答案

A · Report the result before starting, because insulin will push potassium even lower
3.感染控制与患者安全

答案: D · Use the hand lotion approved by the facility to keep the skin intact

为什么是这个答案

Cracked skin is harder to clean and harbors more organisms. Facility-approved lotions help keep the skin healthy without reducing the effect of hand antiseptics such as chlorhexidine.

答案

D · Use the hand lotion approved by the facility to keep the skin intact
4.感染控制与患者安全

答案: B · Stay with the transfusing patient for the first 15 minutes and ask another nurse to help

为什么是这个答案

The most serious reactions, such as acute hemolytic reactions and anaphylaxis, usually start within the first 15 minutes. The nurse stays with the patient during this time and finds another person to help elsewhere.

答案

B · Stay with the transfusing patient for the first 15 minutes and ask another nurse to help
5.实验室检查值与电解质

答案: A · 尿崩症

为什么是这个答案

垂体附近的手术可使抗利尿激素的释放停止。没有它，肾脏会排出大量比重低的稀释尿，钠升高。SIADH 则相反：尿液浓缩、钠低。护士应密切测量出入量并及早报告。核对依据: Diabetes insipidus · MedlinePlus (NIH) (2025); Urine specific gravity test · MedlinePlus (NIH) (2025); Sodium blood test · MedlinePlus (NIH) (2025)

答案

A · 尿崩症
6.实验室检查值与电解质

答案: D · 血清钠低、血清渗透压低、尿液浓缩

为什么是这个答案

抗利尿激素过多导致水潴留，稀释血液（钠和渗透压低），而尿液反常地浓缩。钠高伴尿液非常稀是尿崩症的模式。核对依据: Syndrome of inappropriate antidiuretic hormone secretion · MedlinePlus (NIH) (2025)

答案

D · 血清钠低、血清渗透压低、尿液浓缩
7.临床护理

答案: D · 肠梗阻

为什么是这个答案

肠梗阻引起腹胀、绞痛、呕吐和停止排便排气。患者通常需禁食，并留置鼻胃管进行胃减压。

答案

D · 肠梗阻
8.临床护理

答案: C · 空气栓塞

为什么是这个答案

中心静脉导管与空气相通时可能发生空气栓塞。应夹闭导管，如有可能让患者左侧卧并取头低位，给予高流量吸氧并呼救。

答案

C · 空气栓塞
9.内外科护理：心血管与呼吸

答案: B · Use a mouthpiece or protect the eyes from the mist

为什么是这个答案

Ipratropium is an antimuscarinic bronchodilator. Mist escaping from a face mask can reach the eyes, dilate the pupil and trigger acute angle-closure glaucoma in susceptible patients. A mouthpiece or eye protection reduces the risk.

答案

B · Use a mouthpiece or protect the eyes from the mist
10.内外科护理：心血管与呼吸

答案: C · 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

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

答案: A · 胰岛素使钾进入细胞，因此血钾可能迅速下降

为什么是这个答案

DKA 患者全身钾严重缺乏，即使最初血清钾正常或偏高。胰岛素使钾转移到细胞内，可引起危险的低钾血症。应经常检测钾，并按医嘱加入液体；如果钾很低，可能要推迟胰岛素，直到开始补钾。

答案

A · 胰岛素使钾进入细胞，因此血钾可能迅速下降
12.内外科护理：神经、内分泌与肾脏

答案: C · The patient may not be absorbing their immunosuppressants

为什么是这个答案

Vomiting and diarrhoea can reduce absorption of immunosuppressants, raising the risk of rejection, and dehydration can harm the graft. Tacrolimus levels can also rise with diarrhoea. The team may check levels and kidney function.

答案

C · The patient may not be absorbing their immunosuppressants
13.内外科护理：消化、围手术期与肿瘤

答案: C · It increases gut movement against the blockage

为什么是这个答案

Metoclopramide stimulates gastric and intestinal motility, which can worsen pain and risk perforation in complete mechanical obstruction. Other antiemetics are chosen.

答案

C · It increases gut movement against the blockage
14.内外科护理：消化、围手术期与肿瘤

答案: A · Escalate urgently and start the sepsis pathway

为什么是这个答案

These findings suggest sepsis with poor perfusion. Urgent medical review and a sepsis bundle, including blood cultures, antibiotics within an hour, lactate, fluids and urine output monitoring, improve survival.

答案

A · Escalate urgently and start the sepsis pathway

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