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

A patient on hemodialysis has an arteriovenous fistula in the left arm. Which instruction should the nurse give the nursing assistant?

  1. AMeasure blood pressure on the left arm only, every 4 hours
  2. BDo not measure blood pressure on the left arm
  3. CKeep the left arm wrapped tightly in a bandage at night
  4. DHelp the patient carry shopping bags on the left arm
2.优先排序与委派困难

A nurse returns to the station to find four messages. Which one is answered first?

  1. AA colleague asks to swap shifts with them next week because of a family wedding
  2. BThe laboratory is calling with a critical potassium result of 2.6 mEq/L
  3. CThe pharmacy asks when the next delivery should be scheduled
  4. DA family member wants an update on their father’s progress
3.感染控制与患者安全中等

A nurse finds a used needle in a patient’s bed linen. What should the nurse do?

  1. APick it up by the hub or with forceps, put it in a sharps container and report it
  2. BLeave it where it is for the housekeeping staff to remove later in the day
  3. CFold it into the linen and send it to the laundry
  4. DRecap it with two hands before throwing it away
4.感染控制与患者安全困难

A patient on oxygen needs an MRI scan. Which plan is safe?

  1. ARemove the oxygen for the scan without telling anyone
  2. BTake the usual steel cylinder into the room if it is tightly strapped to the trolley frame
  3. CUse only MRI-safe equipment, and never take a standard steel oxygen cylinder into the scanner room
  4. DLeave the steel cylinder on the patient’s bed during the scan
5.实验室检查值与电解质中等

A patient is starting atorvastatin. Which laboratory test is usually checked at baseline?

  1. ASerum lipase
  2. BBlood cultures
  3. CLiver enzymes
  4. DThyroid antibodies
6.实验室检查值与电解质困难

A patient with right upper abdominal pain from gallstones now has jaundice, a total bilirubin of 4.8 mg/dL (82 µmol/L) and a raised ALP. What is the most likely cause?

  1. AGilbert syndrome triggered by pain
  2. BHemolysis caused by the gallstones
  3. CUncomplicated gallbladder inflammation
  4. DA stone blocking the common bile duct
7.临床护理中等

Why is lactulose given to a patient with hepatic encephalopathy?

  1. ATo lower the blood glucose
  2. BTo increase the liver's production of albumin
  3. CTo stop bleeding from varices
  4. DTo reduce the absorption of ammonia from the gut
8.临床护理困难

一名颅脑损伤患者的 GCS 从 14 分降至 10 分，一侧瞳孔变大且对光反应迟钝。护士应该怎么做？

  1. A鼓励患者睡觉
  2. B给予镇静剂使患者平静
  3. C在下一次常规观察时复查 GCS
  4. D作为神经科急症立即上报
9.内外科护理：心血管与呼吸中等

A patient taking isosorbide mononitrate asks about sildenafil for erectile dysfunction. What is the main danger?

  1. ABleeding from the gums
  2. BA very high potassium level
  3. CSevere hypertension
  4. DSevere hypotension
10.内外科护理：心血管与呼吸困难

During a thrombolytic infusion for an MI, the patient develops a sudden severe headache, vomiting and new confusion. What should the nurse do first?

  1. AGive a second dose to finish the treatment
  2. BStop the infusion and call for urgent medical help
  3. CContinue the infusion, as headache is a common side effect
  4. DSlow the infusion and give an antiemetic
11.内外科护理：神经、内分泌与肾脏中等

A patient with untreated hyperthyroidism is losing weight. Which diet is most appropriate until the condition is controlled?

  1. AA low-calorie diet to protect the heart
  2. BA strict low-protein diet
  3. CA diet very high in caffeine for energy
  4. DA high-calorie diet with enough protein
12.内外科护理：神经、内分泌与肾脏困难

A patient with multiple sclerosis has had worse leg weakness for one day, together with a fever and burning on passing urine. What is the most likely explanation?

  1. AA true relapse that needs high-dose steroids
  2. BA pseudo-relapse caused by infection
  3. CA change to progressive MS
  4. DA side effect of physiotherapy
13.内外科护理：消化、围手术期与肿瘤中等

Which description fits a category (stage) 4 pressure ulcer?

  1. AFull-thickness loss with exposed bone, tendon or muscle
  2. BA blister filled with clear fluid over the heel or sacrum
  3. CA shallow wound into the dermis only
  4. DIntact skin with redness that does not blanch
14.内外科护理：消化、围手术期与肿瘤困难

A patient with small cell lung cancer is confused and drowsy. Sodium is 118 mmol/L and the urine is highly concentrated. Which complication is likely?

  1. AHypercalcaemia of malignancy
  2. BSIADH
  3. CDiabetes insipidus
  4. DTumour lysis syndrome

3溶液

1.优先排序与委派

答案: B · Do not measure blood pressure on the left arm

为什么是这个答案

Blood pressure cuffs, tight bands and heavy loads can damage or block a fistula. The arm with the access is protected, and the nurse checks it for a thrill and bruit.

答案

B · Do not measure blood pressure on the left arm
2.优先排序与委派

答案: B · The laboratory is calling with a critical potassium result of 2.6 mEq/L

为什么是这个答案

A critical potassium of 2.6 mEq/L can cause life-threatening arrhythmias, so it is acted on first: the nurse assesses the patient and informs the provider. The other calls can wait.

答案

B · The laboratory is calling with a critical potassium result of 2.6 mEq/L
3.感染控制与患者安全

答案: A · Pick it up by the hub or with forceps, put it in a sharps container and report it

为什么是这个答案

A loose needle is a hazard to everyone who handles the linen. The nurse disposes of it safely without recapping, using an instrument if needed, and reports the incident so the cause can be addressed.

答案

A · Pick it up by the hub or with forceps, put it in a sharps container and report it
4.感染控制与患者安全

答案: C · Use only MRI-safe equipment, and never take a standard steel oxygen cylinder into the scanner room

为什么是这个答案

Steel oxygen cylinders can become projectiles in an MRI room and cause fatal injuries. Only equipment labeled MRI-safe is used, and the patient’s oxygen needs are planned with the MRI team.

答案

C · Use only MRI-safe equipment, and never take a standard steel oxygen cylinder into the scanner room
5.实验室检查值与电解质

答案: C · Liver enzymes

为什么是这个答案

Statins can raise liver enzymes, so a baseline ALT is usually checked, with a lipid panel to judge response. Routine repeat liver tests are not always needed, but symptoms of liver injury or muscle pain should be reported.

答案

C · Liver enzymes
6.实验室检查值与电解质

答案: D · A stone blocking the common bile duct

为什么是这个答案

A gallstone in the common bile duct (choledocholithiasis) obstructs bile flow, raising conjugated bilirubin and ALP. Fever with jaundice and pain suggests cholangitis, an emergency. Simple cholecystitis usually causes only mild liver test changes.

答案

D · A stone blocking the common bile duct
7.临床护理

答案: D · To reduce the absorption of ammonia from the gut

为什么是这个答案

Lactulose acidifies the colon and speeds transit, reducing ammonia absorption. The dose is usually adjusted to give two to three soft stools a day.

答案

D · To reduce the absorption of ammonia from the gut
8.临床护理

答案: D · 作为神经科急症立即上报

为什么是这个答案

GCS 下降伴单侧瞳孔散大提示颅内压升高、可能发生脑疝。需要紧急医疗评估和影像学检查。

答案

D · 作为神经科急症立即上报
9.内外科护理：心血管与呼吸

答案: D · Severe hypotension

为什么是这个答案

Phosphodiesterase-5 inhibitors such as sildenafil enhance the vasodilator effect of nitrates and can cause profound, life-threatening hypotension. The combination is contraindicated, and patients should tell emergency staff if they have taken one.

答案

D · Severe hypotension
10.内外科护理：心血管与呼吸

答案: B · Stop the infusion and call for urgent medical help

为什么是这个答案

Sudden neurological change during or after thrombolysis suggests intracranial haemorrhage. The infusion is stopped immediately, help is called, and urgent CT and reversal are considered. Neurological observations continue.

答案

B · Stop the infusion and call for urgent medical help
11.内外科护理：神经、内分泌与肾脏

答案: D · A high-calorie diet with enough protein

为什么是这个答案

Excess thyroid hormone raises metabolism, so patients need more calories and protein to prevent weight loss. Caffeine is limited because it worsens palpitations, tremor and anxiety.

答案

D · A high-calorie diet with enough protein
12.内外科护理：神经、内分泌与肾脏

答案: B · A pseudo-relapse caused by infection

为什么是这个答案

Infection and fever can temporarily worsen existing MS symptoms without new damage (a pseudo-relapse). The infection, here probably a UTI, is treated first. Steroids for a true relapse are considered only if the infection is excluded.

答案

B · A pseudo-relapse caused by infection
13.内外科护理：消化、围手术期与肿瘤

答案: A · Full-thickness loss with exposed bone, tendon or muscle

为什么是这个答案

Category 4 has full-thickness loss with exposed bone, tendon or muscle and often undermining or tunnelling. Category 3 reaches the fat but does not expose bone, tendon or muscle.

答案

A · Full-thickness loss with exposed bone, tendon or muscle
14.内外科护理：消化、围手术期与肿瘤

答案: B · SIADH

为什么是这个答案

Small cell lung cancer can secrete ADH, causing water retention, dilutional hyponatraemia and inappropriately concentrated urine. Management includes fluid restriction and careful correction of sodium to avoid osmotic demyelination.

答案

B · SIADH

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