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 is raising his voice, pacing and clenching his fists. What should the nurse do first?

  1. AApply physical restraints at once
  2. BSpeak calmly, keep a safe distance and invite him to talk about what is wrong
  3. CTurn away and ignore the behavior
  4. DStand very close to him and tell him firmly and loudly to sit down and be quiet
2.优先排序与委派困难

At 08:00 a nurse has four tasks. Which order is best?

  1. AGive insulin with breakfast, update care plans, check the patient with a falling SpO₂, give routine medications
  2. BCheck the patient with a falling SpO₂, give insulin with breakfast, give routine medications, update care plans
  3. CGive routine medications, check the patient with a falling SpO₂, update care plans, give insulin with breakfast
  4. DUpdate care plans, give insulin with breakfast, give routine medications, check the patient with a falling SpO₂
3.感染控制与患者安全中等

Before helping a patient from bed into a wheelchair, what should the nurse do with the wheelchair?

  1. APlace it at the foot of the bed, facing away
  2. BLeave the brakes off so the chair can move along with the patient during the pivot
  3. CPlace it on the patient’s weaker side so that side is supported
  4. DLock the brakes and place it close to the bed on the patient’s stronger side
4.感染控制与患者安全困难

A nurse finds an unknown liquid leaking from a container in the utility room, with a strong smell. What should the nurse do first?

  1. AMop it up with paper towels
  2. BPour water over it to dilute it
  3. CLeave the area, keep others out and alert the trained response team
  4. DMove closer and smell it carefully to identify what the substance is
5.实验室检查值与电解质中等

A patient taking phenazopyridine for bladder pain has bright orange urine. What should the nurse know about urine tests?

  1. AThe color shows severe liver failure is present
  2. BThe color proves blood is present in the urine
  3. CThe drug improves the accuracy of all dipsticks
  4. DThe dye can interfere with dipstick color readings
6.实验室检查值与电解质困难

一名血小板计数为 35 × 10³/µL 的患者被开具肌内注射。护士应怎么做？

  1. A用更长的针头注射
  2. B注射后热敷
  3. C按处方注射，并用力按摩注射部位
  4. D询问开医嘱者是否可以改用其他途径
7.临床护理中等

Which is a recognised risk factor for postoperative nausea and vomiting?

  1. AA short operation under local anaesthetic
  2. BBeing a smoker
  3. CBeing male
  4. DUse of opioids after surgery
8.临床护理困难

A patient's hypoglycaemia was caused by a sulfonylurea such as gliclazide or glipizide. Why might they need monitoring for longer than usual?

  1. ASulfonylureas only work at night
  2. BThe drug makes glucose tablets and drinks ineffective
  3. CThe drug causes rebound hyperglycaemia later the same day
  4. DSulfonylureas act for a long time, so hypoglycaemia can recur
9.内外科护理：心血管与呼吸中等

After a prescribed IV fluid bolus for hypotension, what should the nurse do next?

  1. AStart a second fluid bolus straight away without checking anything
  2. BStop all monitoring if the patient says they feel better
  3. CReassess heart rate, blood pressure, urine output and lung sounds
  4. DWait until the next routine observations in four hours
10.内外科护理：心血管与呼吸困难

A patient with lung cancer develops swelling of the face and arms, distended neck and chest veins and breathlessness that is worse when bending forward. What is the most likely cause?

  1. ASuperior vena cava obstruction
  2. BAn allergic reaction to chemotherapy
  3. CRight-sided heart failure
  4. DA deep vein thrombosis in the leg
11.内外科护理：神经、内分泌与肾脏中等

Before surgery for a phaeochromocytoma, why is an alpha-blocker started before any beta-blocker?

  1. AAlpha-blockers lower the blood glucose before surgery
  2. BThe order of the two drugs makes no difference
  3. CA beta-blocker alone can cause a dangerous rise in BP
  4. DBeta-blockers given first would make the tumour grow faster
12.内外科护理：神经、内分泌与肾脏困难

A patient with Addison's disease has been vomiting for a day. They are confused, with BP 78/40 mmHg, sodium 126 mmol/L and potassium 6.0 mmol/L. What is the priority?

  1. AOral hydrocortisone and an antiemetic by mouth
  2. BA fluid restriction for the low sodium
  3. CIV hydrocortisone straight away, plus IV fluids
  4. DIV potassium to correct the electrolytes
13.内外科护理：消化、围手术期与肿瘤中等

造口袋底盘的开口应剪多大？

  1. A略小于造口以便紧密密封
  2. B比造口四周大约 2 cm
  3. C任何大小，只要盖住造口即可
  4. D比造口四周大约 2–3 mm
14.内外科护理：消化、围手术期与肿瘤困难

一名患者正在接受负压伤口治疗。泵报警，敷料失去了密封。最恰当的措施是什么？

  1. A恢复密封；如果及时无法恢复，改用湿性敷料
  2. B在泡沫上用干纱布填塞伤口，并用胶带贴紧
  3. C把吸力调到最大设置以拉回密封
  4. D把泡沫留在伤口内、不吸引，直到数天后复查

3溶液

1.优先排序与委派

答案: B · Speak calmly, keep a safe distance and invite him to talk about what is wrong

为什么是这个答案

Early verbal de-escalation, with a calm voice and a safe distance, is the first approach for rising agitation. Restraint is a last resort, and crowding the patient can make things worse.

答案

B · Speak calmly, keep a safe distance and invite him to talk about what is wrong
2.优先排序与委派

答案: B · Check the patient with a falling SpO₂, give insulin with breakfast, give routine medications, update care plans

为什么是这个答案

A falling SpO₂ is a possible breathing problem and comes first. Insulin must be matched to the meal, routine medications have a time window, and documentation such as care plans comes last.

答案

B · Check the patient with a falling SpO₂, give insulin with breakfast, give routine medications, update care plans
3.感染控制与患者安全

答案: D · Lock the brakes and place it close to the bed on the patient’s stronger side

为什么是这个答案

Locked brakes stop the chair rolling away during the transfer. Placing it close to the bed on the stronger side lets the patient lead with their strong leg.

答案

D · Lock the brakes and place it close to the bed on the patient’s stronger side
4.感染控制与患者安全

答案: C · Leave the area, keep others out and alert the trained response team

为什么是这个答案

An unknown chemical spill may be toxic or flammable. The nurse moves people away, prevents entry and calls the designated hazardous materials team, who check the Safety Data Sheet and use the right equipment.

答案

C · Leave the area, keep others out and alert the trained response team
5.实验室检查值与电解质

答案: D · The dye can interfere with dipstick color readings

为什么是这个答案

Phenazopyridine is a urinary analgesic dye that turns urine orange-red. It can interfere with color-based dipstick tests, so the laboratory should be told. The color is harmless, but it can stain contact lenses and clothing.

答案

D · The dye can interfere with dipstick color readings
6.实验室检查值与电解质

答案: D · 询问开医嘱者是否可以改用其他途径

为什么是这个答案

血小板低时，肌内注射可引起肌肉内出血。护士应要求改用其他途径，如口服或静脉。如果注射不可避免，之后应用力按压而不要按摩。

答案

D · 询问开医嘱者是否可以改用其他途径
7.临床护理

答案: D · Use of opioids after surgery

为什么是这个答案

Known risk factors include opioids, female sex, being a non-smoker, previous PONV or motion sickness and longer general anaesthetics. High-risk patients may be given preventive antiemetics.

答案

D · Use of opioids after surgery
8.临床护理

答案: D · Sulfonylureas act for a long time, so hypoglycaemia can recur

为什么是这个答案

Sulfonylureas stimulate insulin release and have a long duration of action. Hypoglycaemia can be prolonged or recur, so glucose is monitored closely after treatment.

答案

D · Sulfonylureas act for a long time, so hypoglycaemia can recur
9.内外科护理：心血管与呼吸

答案: C · Reassess heart rate, blood pressure, urine output and lung sounds

为什么是这个答案

A fluid challenge is followed by reassessment of perfusion (heart rate, BP, capillary refill, mental state, urine output) and signs of overload such as crackles, raised JVP or worsening breathlessness. The findings are reported to decide on further fluid, vasopressors or escalation.

答案

C · Reassess heart rate, blood pressure, urine output and lung sounds
10.内外科护理：心血管与呼吸

答案: A · Superior vena cava obstruction

为什么是这个答案

A tumour in the mediastinum can compress the superior vena cava, causing swelling of the face, neck and arms, dilated veins on the chest and breathlessness. It is an oncological emergency. The patient is sat upright and given oxygen if hypoxic, and treatment may include a stent, steroids or radiotherapy.

答案

A · Superior vena cava obstruction
11.内外科护理：神经、内分泌与肾脏

答案: C · A beta-blocker alone can cause a dangerous rise in BP

为什么是这个答案

Blocking beta receptors alone leaves catecholamines acting on alpha receptors, causing severe vasoconstriction and a hypertensive crisis. Alpha blockade, such as with phenoxybenzamine, comes first, and a beta-blocker may be added later for tachycardia.

答案

C · A beta-blocker alone can cause a dangerous rise in BP
12.内外科护理：神经、内分泌与肾脏

答案: C · IV hydrocortisone straight away, plus IV fluids

为什么是这个答案

An adrenal crisis is life-threatening. IV or IM hydrocortisone is given immediately, without waiting for tests, together with IV saline and checks of glucose and electrolytes. Vomiting prevents tablets from being absorbed.

答案

C · IV hydrocortisone straight away, plus IV fluids
13.内外科护理：消化、围手术期与肿瘤

答案: D · 比造口四周大约 2–3 mm

为什么是这个答案

开口应剪得紧贴造口周围，留出约 2–3 mm（约 1/8 英寸）的小间隙。太大会使皮肤暴露于排出物；太小可能割伤造口。造口在最初几周内会缩小，所以要重复测量。

答案

D · 比造口四周大约 2–3 mm
14.内外科护理：消化、围手术期与肿瘤

答案: A · 恢复密封；如果及时无法恢复，改用湿性敷料

为什么是这个答案

NPWT 需要气密的密封。如果密封或吸力丧失且不能及时恢复（许多指南规定约 2 小时内），应取出泡沫并换成标准敷料，以降低感染风险。安全间隔由制造商和当地指南规定。

答案

A · 恢复密封；如果及时无法恢复，改用湿性敷料

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