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 with a spinal cord injury at T4 suddenly has a severe headache, flushing above the injury and a blood pressure of 200/110 mmHg. What does the nurse do first?

  1. ASit the patient upright with the legs lowered
  2. BGive a warm drink and recheck the blood pressure in an hour
  3. CApply extra blankets to keep the patient warm and calm
  4. DLay the patient flat with the legs raised
2.优先排序与委派困难

一名患肺炎的老年患者新出现意识模糊。首先采取哪项行动？

  1. A询问家属这对患者来说是否正常
  2. B检查血氧饱和度和其他生命体征
  3. C用腕部约束带阻止患者拉扯静脉输液管
  4. D给予处方的按需镇静药
3.感染控制与患者安全中等

A new antibiotic is prescribed for a patient. What should the nurse check before giving the first dose?

  1. AThe patient’s preferred pharmacy
  2. BOnly the patient’s blood pressure and pulse before giving the drug
  3. COnly the time of the patient’s last meal and drink
  4. DThe patient’s allergies, by checking the record and asking the patient
4.感染控制与患者安全困难

A patient dies after a wrong-drug error, and the hospital carries out a root cause analysis. What is its main focus?

  1. ADeciding whether to tell the family about the error
  2. BIdentifying which staff member made the error and should be disciplined
  3. CEstimating the legal costs for the hospital
  4. DFinding the system and process weaknesses that allowed the error
5.实验室检查值与电解质中等

A patient with type 2 diabetes has a target HbA1c below 7% (53 mmol/mol). Today's result is 7.8% (62 mmol/mol). What is the best interpretation?

  1. AThe patient has had frequent episodes of severe hypoglycemia
  2. BGlucose control has been excellent for the past several months
  3. CThe result shows today's fasting glucose is above the target
  4. DAverage glucose over the past months has been above the target
6.实验室检查值与电解质困难

A patient with jaundice and nausea has a positive IgM antibody to hepatitis A virus (IgM anti-HAV). What does this show?

  1. AChronic hepatitis A lasting many years
  2. BPast hepatitis B infection that has cleared
  3. CA current or recent hepatitis A infection
  4. DImmunity from hepatitis A vaccine long ago
7.临床护理中等

A patient taking a statin reports unexplained muscle pain and weakness. What should the nurse do?

  1. ATell them to double the dose
  2. BReassure them that this is a sign the drug is working
  3. CAdvise more vigorous exercise to work through it
  4. DReport it, as statins can cause muscle damage
8.临床护理困难

An older patient found on the floor after lying there for many hours has dark brown urine and a very high creatine kinase. What is the main risk?

  1. AA urinary tract infection from lying in urine
  2. BA stroke
  3. CAcute kidney injury from rhabdomyolysis
  4. DHypoglycaemia
9.内外科护理：心血管与呼吸中等

A patient on home oxygen has dry, sore lips. Which product is safest to use?

  1. AAn oil-based balm
  2. BAn alcohol-based gel
  3. CA water-based lubricant
  4. DPetroleum jelly
10.内外科护理：心血管与呼吸困难

Four surgical patients need VTE prevention. For which patient is mechanical prophylaxis alone most appropriate?

  1. AA patient with cancer having bowel surgery
  2. BA patient who had a brain haemorrhage two days ago
  3. CAn obese patient after hip surgery
  4. DA patient after an uncomplicated knee replacement
11.内外科护理：神经、内分泌与肾脏中等

Which lifestyle advice best helps a patient with epilepsy reduce their seizures?

  1. ASkip a dose on days without any warning signs
  2. BAvoid all physical exercise and stay indoors
  3. CDrink coffee in the evening to stay alert
  4. DKeep regular sleep and take every dose on time
12.内外科护理：神经、内分泌与肾脏困难

Which patient on a stroke unit is most at risk of falling?

  1. AA patient with a left-hemisphere stroke who has expressive aphasia and waits for help
  2. BA patient with a right-hemisphere stroke who is impulsive and denies having weakness
  3. CA patient with a TIA whose symptoms resolved completely yesterday
  4. DA patient with mild dysarthria who walks steadily with a frame
13.内外科护理：消化、围手术期与肿瘤中等

Which nursing intervention best reduces preoperative anxiety?

  1. AAvoiding talking about the operation at all
  2. BKeeping family members away until after surgery
  3. CTelling the patient that there is nothing to worry about
  4. DExplaining what will happen and answering questions
14.内外科护理：消化、围手术期与肿瘤困难

Which new prescription for a patient with cirrhosis should the nurse question?

  1. ASpironolactone for ascites
  2. BRegular ibuprofen for back pain
  3. CLactulose to keep the bowels open
  4. DThiamine supplements

3溶液

1.优先排序与委派

答案: A · Sit the patient upright with the legs lowered

为什么是这个答案

Autonomic dysreflexia is an emergency in injuries at T6 or above. Sitting the patient up lowers the blood pressure; the nurse then looks for the trigger, most often a full bladder or constipation.

答案

A · Sit the patient upright with the legs lowered
2.优先排序与委派

答案: B · 检查血氧饱和度和其他生命体征

为什么是这个答案

新出现的意识模糊可能由缺氧、脓毒症或低血糖引起。首先评估氧合和生命体征。约束和镇静药处理的是行为而不是病因，并可能使谵妄恶化。

答案

B · 检查血氧饱和度和其他生命体征
3.感染控制与患者安全

答案: D · The patient’s allergies, by checking the record and asking the patient

为什么是这个答案

Before any new drug, the nurse checks recorded allergies and asks the patient directly about past reactions. The patient is then watched closely after the first dose.

答案

D · The patient’s allergies, by checking the record and asking the patient
4.感染控制与患者安全

答案: D · Finding the system and process weaknesses that allowed the error

为什么是这个答案

A root cause analysis looks beyond the individual to the system factors, such as storage, labeling, staffing or workflow, that allowed the error. The aim is to change the system so the error cannot happen again.

答案

D · Finding the system and process weaknesses that allowed the error
5.实验室检查值与电解质

答案: D · Average glucose over the past months has been above the target

为什么是这个答案

An HbA1c of 7.8% shows that average glucose has been above the individual target over about 2–3 months. The nurse explores diet, activity, medication use and barriers, and the treatment plan may be adjusted.核对依据: Hemoglobin A1C (HbA1c) Test · MedlinePlus (NIH) (2025)

答案

D · Average glucose over the past months has been above the target
6.实验室检查值与电解质

答案: C · A current or recent hepatitis A infection

为什么是这个答案

IgM antibodies appear early, so IgM anti-HAV indicates acute hepatitis A. IgG anti-HAV alone shows past infection or vaccination and lifelong immunity. Hepatitis A does not become chronic and spreads by the fecal-oral route, so hand hygiene is essential.核对依据: Hepatitis A · MedlinePlus (NIH) (2025)

答案

C · A current or recent hepatitis A infection
7.临床护理

答案: D · Report it, as statins can cause muscle damage

为什么是这个答案

Statins can cause myopathy and, rarely, rhabdomyolysis. Unexplained muscle symptoms should be reported so creatine kinase can be checked and the drug reviewed.

答案

D · Report it, as statins can cause muscle damage
8.临床护理

答案: C · Acute kidney injury from rhabdomyolysis

为什么是这个答案

Prolonged pressure on muscles causes rhabdomyolysis, releasing myoglobin and potassium. Myoglobin can block kidney tubules; treatment includes IV fluids and close monitoring of urine output and electrolytes.

答案

C · Acute kidney injury from rhabdomyolysis
9.内外科护理：心血管与呼吸

答案: C · A water-based lubricant

为什么是这个答案

Oil-based products such as petroleum jelly can ignite or burn intensely in high oxygen concentrations and have caused facial burns. Water-based products are recommended. Oxygen cylinders are kept upright and secured, away from heat and flames.

答案

C · A water-based lubricant
10.内外科护理：心血管与呼吸

答案: B · A patient who had a brain haemorrhage two days ago

为什么是这个答案

When bleeding risk is high, such as after recent intracranial haemorrhage, mechanical methods (intermittent pneumatic compression) are used instead of anticoagulants until it is safe. The other patients are at high VTE risk and would usually receive pharmacological prophylaxis unless contraindicated.

答案

B · A patient who had a brain haemorrhage two days ago
11.内外科护理：神经、内分泌与肾脏

答案: D · Keep regular sleep and take every dose on time

为什么是这个答案

Missed doses and lack of sleep are among the most common seizure triggers. Excess alcohol and, in some people, flashing lights are others. Most people can exercise safely, with sensible precautions such as not swimming alone.

答案

D · Keep regular sleep and take every dose on time
12.内外科护理：神经、内分泌与肾脏

答案: B · A patient with a right-hemisphere stroke who is impulsive and denies having weakness

为什么是这个答案

Right-hemisphere strokes often cause left-sided neglect, poor judgement, impulsivity and denial of the deficit. These patients may try to get up alone. Patients with left-hemisphere strokes are often more cautious.

答案

B · A patient with a right-hemisphere stroke who is impulsive and denies having weakness
13.内外科护理：消化、围手术期与肿瘤

答案: D · Explaining what will happen and answering questions

为什么是这个答案

Clear information about what to expect, including pain control and recovery, reduces anxiety and can improve recovery. False reassurance does not address the patient's concerns.

答案

D · Explaining what will happen and answering questions
14.内外科护理：消化、围手术期与肿瘤

答案: B · Regular ibuprofen for back pain

为什么是这个答案

NSAIDs can cause kidney injury, fluid retention and GI bleeding in cirrhosis and should be avoided. Paracetamol at a reduced, carefully reviewed dose is usually preferred for pain.

答案

B · Regular ibuprofen for back pain

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