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

对于髋关节置换术后两天的患者，哪项任务适合护理助理？

  1. A检查切口有无发红、发热和渗出
  2. B按髋关节注意事项协助患者坐到椅子上
  3. C评估上一剂止痛药是否控制了疼痛
  4. D出院前教患者髋关节注意事项
2.优先排序与委派困难

After the RN taught a patient to inject insulin, an LPN/LVN reports that the patient still cannot draw up the dose correctly. What should happen next?

  1. AThe LPN/LVN writes a new teaching plan and evaluates it at the end of the shift
  2. BThe nursing assistant shows the patient again at lunch
  3. CThe RN reassesses the patient’s learning needs and adjusts the teaching
  4. DThe patient is discharged with a leaflet to read at home
3.感染控制与患者安全中等

为什么对胰岛素和肝素输注等某些药物要采用独立双人核对？

  1. A万一出错，可以由两名护士共同承担责任
  2. B因为这些药物很昂贵，浪费不起
  3. C由第二人单独核对，可以发现被漏掉的差错
  4. D使配药过程更快
4.感染控制与患者安全困难

A nurse asks a colleague to “just glance” at an insulin infusion before starting it. What makes a check truly independent?

  1. AThe first nurse reads the details aloud and the second agrees
  2. BThe second nurse checks the order, drug, dose and pump settings separately without being told the answer
  3. CThe second nurse looks at the bag label from the doorway
  4. DThe second nurse signs the record after the infusion has already been started by the first
5.实验室检查值与电解质中等

A patient with type 2 diabetes starts prednisone each morning. When is the glucose most likely to be highest?

  1. AIn the afternoon and evening
  2. BAt midnight only
  3. CIn the early morning, before the dose
  4. DThe glucose will not change
6.实验室检查值与电解质困难

A patient with thalassemia major has received regular red cell transfusions for years. The ferritin is now very high. What does this most likely show, and what treatment is used?

  1. AIron deficiency, treated with IV iron supplements
  2. BAcute infection, treated with broad-spectrum antibiotics
  3. CLiver failure, treated with a liver transplant at once
  4. DIron overload, treated with iron chelation therapy
7.临床护理中等

A patient is having a 12-lead ECG. Where are the chest electrodes placed?

  1. AIn standard numbered positions across the front and left of the chest
  2. BOn both shoulders and both hips only
  3. CAnywhere on the chest where the skin is clear
  4. DIn a straight line down the centre of the sternum from top to bottom
8.临床护理困难

A patient has a full-thickness burn all the way round the forearm. Which complication must be watched for closely?

  1. ADelayed hair growth on the arm
  2. BLoss of circulation to the hand as swelling builds under tight burned skin
  3. CExcessive bleeding from the burn surface needing an urgent blood transfusion
  4. DHypoglycaemia caused by the body using glucose to heal the burn
9.内外科护理：心血管与呼吸中等

Where is the V1 electrode placed for a 12-lead ECG?

  1. AThe fourth intercostal space just right of the sternum
  2. BJust below the left collarbone
  3. CThe fifth intercostal space in the mid-axillary line
  4. DOver the left nipple
10.内外科护理：心血管与呼吸困难

一名使用 28% 文丘里面罩（SpO₂ 90%）的 COPD 患者想吃饭。最恰当的方案是什么？

  1. A进餐期间改用 15 L/min 的非重复呼吸面罩
  2. B进餐期间完全撤掉氧气，之后再恢复
  3. C继续戴文丘里面罩，只通过吸管喝流质
  4. D改用低流量鼻导管，使 SpO₂ 保持在 88–92%
11.内外科护理：神经、内分泌与肾脏中等

Which measure best prevents catheter-associated urinary tract infection?

  1. ADisconnect the bag regularly to empty it
  2. BKeep the drainage bag above bladder level
  3. CChange the catheter for a new one every day
  4. DRemove the catheter as soon as it is no longer needed
12.内外科护理：神经、内分泌与肾脏困难

A man with chronic urinary retention is catheterised. Over the next hours he passes very large volumes of urine. What is the main nursing concern?

  1. AA rise in blood glucose from the urine
  2. BA urinary infection caused by the high flow of urine
  3. CFluid and electrolyte loss from post-obstructive diuresis
  4. DRupture of the bladder from the catheter
13.内外科护理：消化、围手术期与肿瘤中等

Which statement about moist wound healing is correct?

  1. AA wet wound bed always prevents infection
  2. BWounds heal fastest when left to dry out and form a scab
  3. CWounds should be soaked in water for hours every day
  4. DA moist, not wet, wound bed helps cells move and heal faster
14.内外科护理：消化、围手术期与肿瘤困难

髋部手术后第 3 天，一名老年患者急性意识混乱，注意力波动并躁动。护士首先应做什么？

  1. A请家人把患者接回家，让其安定下来
  2. B认为这是痴呆，并保持护理计划不变
  3. C寻找低氧、感染、疼痛或药物等原因，并上报
  4. D约束患者并立即给予大剂量镇静药

3溶液

1.优先排序与委派

答案: B · 按髋关节注意事项协助患者坐到椅子上

为什么是这个答案

按护理计划中已设定的注意事项协助病情稳定的患者活动，是常规任务。检查伤口、教育和评价止痛效果需要护理评估。

答案

B · 按髋关节注意事项协助患者坐到椅子上
2.优先排序与委派

答案: C · The RN reassesses the patient’s learning needs and adjusts the teaching

为什么是这个答案

Evaluating learning and changing the teaching plan belong to the RN. The LPN/LVN can reinforce teaching, but a teaching plan that is not working needs RN reassessment.

答案

C · The RN reassesses the patient’s learning needs and adjusts the teaching
3.感染控制与患者安全

答案: C · 由第二人单独核对，可以发现被漏掉的差错

为什么是这个答案

在独立双人核对中，第二名有资质的人员自行核对医嘱、药物、剂量、计算和泵的设置。这可以发现高警示药物中可能造成严重伤害的差错。

答案

C · 由第二人单独核对，可以发现被漏掉的差错
4.感染控制与患者安全

答案: B · The second nurse checks the order, drug, dose and pump settings separately without being told the answer

为什么是这个答案

In an independent double check, the second person works through each step on their own, then the two results are compared. Reading the answer aloud or glancing invites confirmation bias.

答案

B · The second nurse checks the order, drug, dose and pump settings separately without being told the answer
5.实验室检查值与电解质

答案: A · In the afternoon and evening

为什么是这个答案

A morning dose of prednisone raises glucose mainly in the afternoon and evening, with a smaller effect overnight. Glucose monitoring and insulin plans often target these times, and doses are adjusted when the steroid is tapered.

答案

A · In the afternoon and evening
6.实验室检查值与电解质

答案: D · Iron overload, treated with iron chelation therapy

为什么是这个答案

The body has no active way to excrete iron, so repeated transfusions cause iron overload, which can damage the heart, liver and endocrine glands. A very high ferritin reflects this, and iron chelators are used to remove the excess.

答案

D · Iron overload, treated with iron chelation therapy
7.临床护理

答案: A · In standard numbered positions across the front and left of the chest

为什么是这个答案

The six chest leads (V1–V6) have standard anatomical positions, from the 4th intercostal space beside the sternum to the mid-axillary line. Wrong placement can change the ECG and lead to misinterpretation.

答案

A · In standard numbered positions across the front and left of the chest
8.临床护理

答案: B · Loss of circulation to the hand as swelling builds under tight burned skin

为什么是这个答案

Circumferential full-thickness burns form a tight eschar that acts like a tourniquet as oedema develops. Neurovascular checks are needed, and escharotomy may be required.

答案

B · Loss of circulation to the hand as swelling builds under tight burned skin
9.内外科护理：心血管与呼吸

答案: A · The fourth intercostal space just right of the sternum

为什么是这个答案

V1 is placed in the fourth intercostal space at the right sternal edge, and V2 at the left sternal edge. V4 is in the fifth intercostal space in the mid-clavicular line, and V6 in the mid-axillary line at the same level. Wrong placement can mimic or hide changes.

答案

A · The fourth intercostal space just right of the sternum
10.内外科护理：心血管与呼吸

答案: D · 改用低流量鼻导管，使 SpO₂ 保持在 88–92%

为什么是这个答案

氧疗是按目标范围开具的，需要吸氧的患者不应因进餐而停氧。鼻导管便于进食和说话；流量（例如 1–2 L/min）经滴定使饱和度保持在目标范围内。高浓度氧气有高碳酸血症的风险。

答案

D · 改用低流量鼻导管，使 SpO₂ 保持在 88–92%
11.内外科护理：神经、内分泌与肾脏

答案: D · Remove the catheter as soon as it is no longer needed

为什么是这个答案

The risk of CAUTI rises with each day a catheter is in place. Avoiding unnecessary catheters and removing them early are the most effective measures. A closed system and keeping the bag below bladder level also help.

答案

D · Remove the catheter as soon as it is no longer needed
12.内外科护理：神经、内分泌与肾脏

答案: C · Fluid and electrolyte loss from post-obstructive diuresis

为什么是这个答案

After relief of chronic obstruction, the kidneys may pass large volumes of urine and salt. Hypovolaemia and electrolyte problems can follow. Strict fluid balance, blood pressure checks and electrolyte monitoring are needed.

答案

C · Fluid and electrolyte loss from post-obstructive diuresis
13.内外科护理：消化、围手术期与肿瘤

答案: D · A moist, not wet, wound bed helps cells move and heal faster

为什么是这个答案

A moist environment supports cell migration, autolytic debridement and less pain. Too much moisture causes maceration, so dressings are chosen to balance exudate.

答案

D · A moist, not wet, wound bed helps cells move and heal faster
14.内外科护理：消化、围手术期与肿瘤

答案: C · 寻找低氧、感染、疼痛或药物等原因，并上报

为什么是这个答案

急性意识混乱伴注意力波动提示谵妄。它是一种医疗急症，可能有许多原因，如低氧、脓毒症、疼痛、药物（包括阿片类和抗胆碱能药物）、尿潴留、便秘、脱水和电解质问题。应治疗病因，采用非药物措施，镇静仅作为最后手段。

答案

C · 寻找低氧、感染、疼痛或药物等原因，并上报

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