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 nursing assistant tells the RN that a patient’s IV pump is alarming. What is the best response?

  1. A“Silence the alarm and I will check it at the end of the shift.”
  2. B“Increase the rate a little so the alarm clears.”
  3. C“I will come and check the pump and the IV site now.”
  4. D“Turn the pump off and on again until it stops.”
2.优先排序与委派困难

Which patient finding after a total knee replacement needs the nurse’s action first?

  1. APain of 4/10 when the physiotherapist bends the knee during the morning session
  2. BAsks for an ice pack to help with swelling around the knee
  3. CSudden calf pain and swelling in the operated leg, with new breathlessness
  4. DA small amount of dried blood on the dressing
3.感染控制与患者安全中等

条码扫描器提示药物与患者记录不符。护士应怎么做？

  1. A暂停并查明原因后再给药
  2. B扫描另一位患者的腕带
  3. C先给药，本班稍后再报告该警告
  4. D忽略警告并给药
4.感染控制与患者安全困难

A nurse discovers that an insulin infusion was programmed using the wrong drug concentration in the pump library. What should the nurse do first?

  1. AReprogram the pump and finish the shift before reporting
  2. BDouble the rate to correct for the error
  3. CLeave it running and check the glucose at the next routine time
  4. DStop the infusion and check the patient’s blood glucose
5.实验室检查值与电解质中等

How should a patient collect a clean-catch midstream urine sample?

  1. ACollect urine from the toilet bowl after voiding into the toilet
  2. BFill the cup completely, then add tap water if there is not enough
  3. CClean the area, start voiding into the toilet, then catch the middle part
  4. DCollect the very first urine of the stream directly in the sterile cup
6.实验室检查值与电解质困难

A patient has taken metformin for 8 years and now has numbness in the feet, a hemoglobin of 10.2 g/dL (102 g/L) and an MCV of 108 fL. Which deficiency is most likely?

  1. AVitamin K deficiency
  2. BVitamin D (calciferol) deficiency
  3. CVitamin B12 deficiency
  4. DIron deficiency from gut loss
7.临床护理中等

Why does a patient with a suspected TIA need urgent specialist assessment?

  1. AThe patient needs urgent surgery on the brain
  2. BThe risk of a full stroke is highest in the days after a TIA
  3. CThe symptoms will come back permanently within an hour
  4. DA TIA always turns into a brain tumour unless it is treated
8.临床护理困难

A catheterised postoperative patient has passed only 10 mL of urine in the last two hours. What should the nurse check first?

  1. AWhether the patient has eaten breakfast
  2. BThe patient's weight from last year
  3. CThe patient's cholesterol level from the admission bloods
  4. DThat the catheter and tubing are not kinked or blocked
9.内外科护理：心血管与呼吸中等

How should a patient breathe in when using a pressurised metered-dose inhaler without a spacer?

  1. ASlowly and deeply while pressing the canister, then hold the breath
  2. BIn short gasps through the nose while pressing the canister
  3. CNormally, while breathing out through the mouthpiece
  4. DAs hard and fast as possible, then press the canister afterwards
10.内外科护理：心血管与呼吸困难

A patient with COPD who is known to retain CO₂ arrives on 15 L/min oxygen. They are now drowsy with SpO₂ 99%. What is the most appropriate action?

  1. ARemove the oxygen completely and observe
  2. BGive a sedative to help the patient rest
  3. CReduce the oxygen to aim for 88–92% and get a blood gas
  4. DKeep the oxygen at 15 L/min because the saturation is excellent
11.内外科护理：神经、内分泌与肾脏中等

How does the nurse test the facial nerve (VII)?

  1. AAsk them to raise the eyebrows, shut the eyes tightly and smile
  2. BShine a light in each eye and check the pupil response
  3. CAsk the patient to stick out the tongue and move it from side to side
  4. DTouch the forehead, cheek and chin with cotton wool
12.内外科护理：神经、内分泌与肾脏困难

A patient with known back pain says they now cannot feel the skin between their legs and have not passed urine for 12 hours. What should happen?

  1. AUrgent MRI and referral to the spinal surgeons
  2. BAdvice to rest at home and take stronger painkillers
  3. CA laxative and review in the clinic in a month
  4. DA routine physiotherapy appointment next week
13.内外科护理：消化、围手术期与肿瘤中等

Why do patients usually have a dental review before radiotherapy to the head and neck?

  1. ATeeth block the radiation beam completely
  2. BRadiotherapy can only be given once all the teeth have been removed
  3. CThe dentist gives the radiotherapy
  4. DIt causes dry mouth and raises the risk of decay and jaw damage
14.内外科护理：消化、围手术期与肿瘤困难

A patient took a large paracetamol (acetaminophen) overdose 6 hours ago and says they feel completely well. Which statement is correct?

  1. ATreatment is not needed if the patient has not vomited
  2. BFeeling well means the dose was too small to cause harm
  3. CLiver damage may still develop, and appears only days later
  4. DLiver damage after paracetamol occurs only within the first hour or so

3溶液

1.优先排序与委派

答案: C · “I will come and check the pump and the IV site now.”

为什么是这个答案

An alarm may mean an occlusion, air in the line or infiltration. The nurse checks the pump and site; the assistant should not adjust the pump or silence alarms.

答案

C · “I will come and check the pump and the IV site now.”
2.优先排序与委派

答案: C · Sudden calf pain and swelling in the operated leg, with new breathlessness

为什么是这个答案

Calf pain and swelling suggest deep vein thrombosis, and new breathlessness raises concern for a pulmonary embolism. This needs immediate assessment and escalation; the other findings are expected.

答案

C · Sudden calf pain and swelling in the operated leg, with new breathlessness
3.感染控制与患者安全

答案: A · 暂停并查明原因后再给药

为什么是这个答案

条码警告的作用是发现患者错误、药物错误和剂量错误。护士应暂停，核对医嘱和药品，并联系药房或开医嘱者。出于习惯而忽略警告会导致差错。

答案

A · 暂停并查明原因后再给药
4.感染控制与患者安全

答案: D · Stop the infusion and check the patient’s blood glucose

为什么是这个答案

A concentration error means the dose delivered was wrong. The nurse stops the infusion, assesses the patient including blood glucose, treats as needed, notifies the prescriber and reports the event.

答案

D · Stop the infusion and check the patient’s blood glucose
5.实验室检查值与电解质

答案: C · Clean the area, start voiding into the toilet, then catch the middle part

为什么是这个答案

Cleaning the urethral area and discarding the first part of the stream reduce contamination from skin and urethral bacteria. The inside of the sterile container must not be touched, and the sample should reach the laboratory promptly.核对依据: Clean catch urine sample · MedlinePlus (NIH) (2024)

答案

C · Clean the area, start voiding into the toilet, then catch the middle part
6.实验室检查值与电解质

答案: C · Vitamin B12 deficiency

为什么是这个答案

Long-term metformin reduces vitamin B12 absorption in the gut. B12 deficiency causes macrocytic anemia and peripheral neuropathy, which can be mistaken for diabetic neuropathy. Periodic B12 testing is recommended for long-term users.核对依据: Vitamin B Test · MedlinePlus (NIH) (2026)

答案

C · Vitamin B12 deficiency
7.临床护理

答案: B · The risk of a full stroke is highest in the days after a TIA

为什么是这个答案

The risk of stroke is highest soon after a TIA. Rapid assessment and treatment, such as antiplatelets, statins and carotid imaging, reduce this risk.

答案

B · The risk of a full stroke is highest in the days after a TIA
8.临床护理

答案: D · That the catheter and tubing are not kinked or blocked

为什么是这个答案

A sudden fall in catheter output may be due to a kinked, clamped or blocked catheter. If it is draining freely, the nurse assesses fluid status and vital signs and escalates possible hypovolaemia or AKI.

答案

D · That the catheter and tubing are not kinked or blocked
9.内外科护理：心血管与呼吸

答案: A · Slowly and deeply while pressing the canister, then hold the breath

为什么是这个答案

With a metered-dose inhaler, the patient breathes out, starts a slow deep breath, presses the canister at the start of it and then holds the breath for about 10 seconds. Coordination is difficult, which is why spacers are often used.

答案

A · Slowly and deeply while pressing the canister, then hold the breath
10.内外科护理：心血管与呼吸

答案: C · Reduce the oxygen to aim for 88–92% and get a blood gas

为什么是这个答案

In patients at risk of hypercapnic respiratory failure, excess oxygen can raise PaCO₂ and cause drowsiness and acidosis. Oxygen is stepped down to a target of 88–92% (for example via a Venturi mask), not stopped abruptly, which could cause dangerous hypoxaemia. An arterial blood gas guides further treatment, which may include NIV.

答案

C · Reduce the oxygen to aim for 88–92% and get a blood gas
11.内外科护理：神经、内分泌与肾脏

答案: A · Ask them to raise the eyebrows, shut the eyes tightly and smile

为什么是这个答案

The facial nerve moves the muscles of the face. Asking the patient to raise the eyebrows, close the eyes, puff the cheeks and smile shows any weakness. Facial sensation is carried by the trigeminal nerve.

答案

A · Ask them to raise the eyebrows, shut the eyes tightly and smile
12.内外科护理：神经、内分泌与肾脏

答案: A · Urgent MRI and referral to the spinal surgeons

为什么是这个答案

Saddle anaesthesia with urinary retention suggests cauda equina syndrome. Delay can lead to permanent bladder, bowel and sexual dysfunction. The patient needs an emergency MRI and surgical decompression if confirmed.

答案

A · Urgent MRI and referral to the spinal surgeons
13.内外科护理：消化、围手术期与肿瘤

答案: D · It causes dry mouth and raises the risk of decay and jaw damage

为什么是这个答案

Head and neck radiotherapy damages salivary glands, causing xerostomia and dental decay, and can cause osteoradionecrosis of the jaw after extractions. Dental treatment is done first, with careful oral hygiene and fluoride.

答案

D · It causes dry mouth and raises the risk of decay and jaw damage
14.内外科护理：消化、围手术期与肿瘤

答案: C · Liver damage may still develop, and appears only days later

为什么是这个答案

Early after paracetamol overdose, patients often have no or few symptoms, but liver injury peaks after about 3–4 days. Treatment with acetylcysteine is guided by timed paracetamol levels and the history.

答案

C · Liver damage may still develop, and appears only days later

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