NCLEX 风格的优先排序与委派：速成包

一名生命体征正常、病情稳定的成人手上有一处需要缝合的伤口，别无其他问题。哪个 ESI 级别合适？

1. A5 级
2. B4 级
3. C3 级
4. D2 级

A nurse teaches a patient to inject enoxaparin at home. Which statement shows a need for further teaching?

1. A“I will change the injection site each time.”
2. B“I will inject into the fat of my abdomen, away from the navel.”
3. C“I will rub the area after the injection to help it absorb.”
4. D“I will tell my doctor if I notice unusual bruising or bleeding.”

A patient on oxygen is being taken to another department by wheelchair. What should the nurse check first?

1. AThat the oxygen is turned off during the transfer to save the supply in the tank
2. BThat the cylinder is placed on the patient’s lap
3. CThat the portable cylinder has enough oxygen for the whole trip
4. DThat the cylinder is the largest size available

A nurse teaches a patient going home with an MRSA wound infection. Which statement shows a need for further teaching?

1. A“I will put used dressings in a sealed bag before throwing them out.”
2. B“I will keep the wound covered with a clean, dry dressing.”
3. C“I will wash my hands after touching my dressing.”
4. D“I can share towels with my family if I wash them every week.”

静脉注射葡萄糖酸钙如何帮助重度高钾血症患者？

1. A在肠道中结合钾，使其随粪便排出
2. B增加肾脏对钾的排泄
3. C使钾从血液转移到细胞内
4. D稳定心肌细胞膜，但不降低钾

A patient on warfarin with an INR of 3.6 fell and hit their head an hour ago. They now report a worsening headache and drowsiness. What is the priority?

1. AReport urgently for imaging and possible reversal
2. BEncourage rest in a dark room to settle the pain
3. CHold warfarin for one dose and observe at home
4. DGive acetaminophen (paracetamol) and recheck the INR tomorrow

一名服用地高辛的患者出现恶心，脉搏 48 次/分，并说看什么都是黄色的。你应怀疑什么？

1. A低血糖
2. B无须处理的正常副作用
3. C地高辛中毒
4. D甲状腺功能亢进

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. AGive a long-acting carbohydrate snack only and recheck tomorrow
2. BGive a dose of subcutaneous insulin
3. CTake no action because the level is rising
4. DGive another dose of fast-acting carbohydrate and recheck

When should an adult with cystic fibrosis take pancreatic enzyme capsules?

1. AOnce a day on waking, at least an hour before any food
2. BOnly at bedtime
3. CWith all meals and snacks that contain fat
4. DOnly when they have diarrhoea

Which task for a stable patient with heart failure can the registered nurse most appropriately delegate to a healthcare assistant (unlicensed assistive personnel)?

1. ATeaching the patient about a low-salt diet
2. BDeciding whether to give the furosemide dose
3. CAssessing lung sounds for new crackles
4. DMeasuring and recording the morning weight

Which nursing action helps most to prevent and manage delirium in an older inpatient?

1. AMove the patient to a different room each day for variety
2. BKeep the lights on all night so the patient can see clearly
3. CUse glasses and hearing aids and reorient the patient often
4. DRestrain the patient so that they do not wander off the ward

A patient on insulin has worsening chronic kidney disease and is having more hypos. What is the best explanation?

1. AThe patient is eating far more carbohydrate than before
2. BKidney disease makes the body resistant to insulin
3. CKidney disease makes the meter read too low
4. DThe kidneys clear less insulin, so it lasts longer

In the SBAR communication tool, what belongs under "A"?

1. AThe address and phone number of the patient's next of kin
2. BA list of the patient's allergies only
3. CThe nurse's assessment of what the problem is
4. DThe patient's admission date only

一名肺癌患者出现面部肿胀、颈静脉怒张，平卧时呼吸困难加重。可能是哪种急症？

1. A恶性肿瘤相关高钙血症
2. B脊髓压迫
3. C大面积肺栓塞
4. D上腔静脉阻塞