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 drowsy patient has an arterial blood gas with pH 7.30, PaCO₂ 58 mmHg (7.7 kPa) and HCO₃⁻ 25 mEq/L (mmol/L). Which problem is the priority?

  1. AHyperventilation caused by anxiety
  2. BToo much bicarbonate from antacids
  3. CPoor ventilation causing carbon dioxide to build up
  4. DLoss of bicarbonate from the bowel through severe diarrhea
2.优先排序与委派困难

After a head injury, a patient passes large amounts of very dilute urine, is thirsty and has a rising serum sodium. Which condition is most likely?

  1. ADiabetes insipidus
  2. BSIADH
  3. CDiabetic ketoacidosis
  4. DAcute kidney injury with oliguria
3.感染控制与患者安全中等

Where should the dispersive (grounding) pad for electrosurgery be placed?

  1. AOn clean, dry skin over a well-perfused muscle, close to the surgical site
  2. BOn skin that is wet with antiseptic prep
  3. COver an area with scar tissue or a tattoo, so that the pad does not slip
  4. DOver a bony prominence such as the hip bone
4.感染控制与患者安全困难

During a disaster, the hospital needs to free beds quickly. Which patient is the best candidate for early discharge?

  1. AA patient with ongoing chest pain awaiting cardiac tests
  2. BA patient on a ventilator in the intensive care unit who is slowly improving
  3. CA patient on an IV heparin infusion that is still being adjusted
  4. DA patient admitted overnight for observation who is now stable with normal tests
5.实验室检查值与电解质中等

A woman with hyperemesis gravidarum has vomited for 3 days. Which urine finding would the nurse expect?

  1. ABilirubin
  2. BNitrites
  3. CRed cell casts
  4. DKetones
6.实验室检查值与电解质困难

A patient has marked generalized edema. Results show heavy proteinuria, serum albumin 1.8 g/dL (18 g/L) and total cholesterol 340 mg/dL (8.8 mmol/L). Which condition fits best?

  1. ALiver cirrhosis only
  2. BPrerenal kidney injury
  3. CAcute pyelonephritis
  4. DNephrotic syndrome
7.临床护理中等

A patient with leukaemia has a very low platelet count. Which nursing precaution is appropriate?

  1. AGive medicines by intramuscular injection
  2. BTake temperatures rectally
  3. CEncourage contact sports to keep fit
  4. DUse a soft toothbrush and an electric razor
8.临床护理困难

A patient going home with a leg cast is taught about cast care. Which statement shows a need for further teaching?

  1. A"I will come back if my toes go numb or turn blue."
  2. B"I can push a knitting needle down the cast to scratch an itch."
  3. C"I will keep my leg raised on pillows for the first few days."
  4. D"I will keep the cast dry."
9.内外科护理：心血管与呼吸中等

A patient is on a short course of oral prednisolone for an asthma exacerbation. Which effect should the nurse monitor for?

  1. ARaised blood glucose
  2. BLow blood pressure
  3. CSlow heart rate
  4. DLow blood sodium
10.内外科护理：心血管与呼吸困难

A patient with severe aortic stenosis is prescribed glyceryl trinitrate (nitroglycerin) for chest pain. Why should the nurse use particular caution?

  1. AVasodilators can cause a severe fall in BP with a fixed outflow obstruction
  2. BThere is no reason for caution, because GTN acts only on the coronary arteries
  3. CGTN raises the blood pressure dangerously in aortic stenosis
  4. DGTN makes the narrowed aortic valve tighten further within a few minutes
11.内外科护理：神经、内分泌与肾脏中等

After transsphenoidal pituitary surgery, which advice should the patient follow?

  1. ADrink through a straw to keep the nose clean
  2. BBlow the nose often to clear any clots
  3. CAvoid blowing the nose, straining and bending forward
  4. DLie completely flat for at least a week after surgery
12.内外科护理：神经、内分泌与肾脏困难

A kidney transplant recipient has had vomiting and diarrhoea for two days. Why should the transplant team be contacted?

  1. AVomiting proves that rejection has already happened
  2. BThe kidney will start to produce far too much urine
  3. CThe tablets will make the vomiting stop
  4. DThe patient may not be absorbing their immunosuppressants
13.内外科护理：消化、围手术期与肿瘤中等

哪些床旁评估用于追踪腹水？

  1. A每餐前的毛细血管血糖
  2. B每日体重和腹围
  3. C峰流速和血氧饱和度
  4. D每天两次的瞳孔大小和反应
14.内外科护理：消化、围手术期与肿瘤困难

开始治疗高级别淋巴瘤的化疗两天后，一名患者尿量减少；血钾 6.4 mmol/L，磷酸盐高，钙低。护士应怀疑什么并如何处理？

  1. A过敏反应：给抗组胺药，照常继续
  2. B肿瘤溶解综合征：上报，开始心电监护，并预期静脉补液
  3. C单纯脱水：鼓励口服液体，下周复查血液
  4. D预期的化疗副作用：下一个周期前无需处理

3溶液

1.优先排序与委派

答案: C · Poor ventilation causing carbon dioxide to build up

为什么是这个答案

A low pH with a high PaCO₂ and normal bicarbonate is respiratory acidosis. The patient is not breathing out enough carbon dioxide, so the priority is to support ventilation and escalate.

答案

C · Poor ventilation causing carbon dioxide to build up
2.优先排序与委派

答案: A · Diabetes insipidus

为什么是这个答案

Damage to the pituitary or hypothalamus can stop the release of antidiuretic hormone, causing diabetes insipidus. The patient loses water, so urine is dilute and sodium rises; SIADH causes the opposite.

答案

A · Diabetes insipidus
3.感染控制与患者安全

答案: A · On clean, dry skin over a well-perfused muscle, close to the surgical site

为什么是这个答案

The pad returns the current safely. Good contact over a well-perfused muscle prevents burns, while bony areas, scars, hair and moisture reduce contact and can cause burns at the pad site.

答案

A · On clean, dry skin over a well-perfused muscle, close to the surgical site
4.感染控制与患者安全

答案: D · A patient admitted overnight for observation who is now stable with normal tests

为什么是这个答案

In a surge, stable patients who could be safely cared for at home are discharged first. Patients who are unstable or need close monitoring or titrated infusions must stay.

答案

D · A patient admitted overnight for observation who is now stable with normal tests
5.实验室检查值与电解质

答案: D · Ketones

为什么是这个答案

Prolonged vomiting and poor intake lead to fat breakdown and ketonuria, along with dehydration and electrolyte loss such as hypokalemia. Urine ketones help assess severity and response to IV fluids and antiemetics.核对依据: Ketones urine test · MedlinePlus (NIH) (2025)

答案

D · Ketones
6.实验室检查值与电解质

答案: D · Nephrotic syndrome

为什么是这个答案

Nephrotic syndrome is heavy proteinuria with low albumin, edema and high lipids. Low albumin reduces oncotic pressure, causing edema, and the liver increases lipoprotein production. There is also a higher risk of clots and infection.核对依据: Nephrotic syndrome · MedlinePlus (NIH) (2025)

答案

D · Nephrotic syndrome
7.临床护理

答案: D · Use a soft toothbrush and an electric razor

为什么是这个答案

Thrombocytopenia increases bleeding risk. Gentle oral care, electric razors and avoiding IM injections and rectal procedures help prevent bleeding.

答案

D · Use a soft toothbrush and an electric razor
8.临床护理

答案: B · "I can push a knitting needle down the cast to scratch an itch."

为什么是这个答案

Pushing objects under a cast can injure the skin and cause infection or pressure sores. Elevation, keeping the cast dry and reporting numbness, colour change or increasing pain are correct.

答案

B · "I can push a knitting needle down the cast to scratch an itch."
9.内外科护理：心血管与呼吸

答案: A · Raised blood glucose

为什么是这个答案

Corticosteroids raise blood glucose, which matters especially in diabetes. Short courses can also cause mood changes, insomnia, indigestion and fluid retention. Long-term use adds osteoporosis, adrenal suppression and infection risk.

答案

A · Raised blood glucose
10.内外科护理：心血管与呼吸

答案: A · Vasodilators can cause a severe fall in BP with a fixed outflow obstruction

为什么是这个答案

In severe aortic stenosis, cardiac output is fixed by the narrow valve. Vasodilators lower preload and afterload, and the heart cannot compensate, so the blood pressure can fall sharply and cause syncope. They are used with care and close monitoring.

答案

A · Vasodilators can cause a severe fall in BP with a fixed outflow obstruction
11.内外科护理：神经、内分泌与肾脏

答案: C · Avoid blowing the nose, straining and bending forward

为什么是这个答案

Raised pressure in the head can open the repair and cause a CSF leak. Patients avoid nose blowing, straining, coughing hard and bending forward, and sneeze with the mouth open. Straws may also be avoided.

答案

C · Avoid blowing the nose, straining and bending forward
12.内外科护理：神经、内分泌与肾脏

答案: D · The patient may not be absorbing their immunosuppressants

为什么是这个答案

Vomiting and diarrhoea can reduce absorption of immunosuppressants, raising the risk of rejection, and dehydration can harm the graft. Tacrolimus levels can also rise with diarrhoea. The team may check levels and kidney function.

答案

D · The patient may not be absorbing their immunosuppressants
13.内外科护理：消化、围手术期与肿瘤

答案: B · 每日体重和腹围

为什么是这个答案

每日体重和在同一标记水平测量的腹围可显示腹水是在增加还是减少。还应监测液体平衡、肾功能和电解质，尤其是在使用利尿剂时。

答案

B · 每日体重和腹围
14.内外科护理：消化、围手术期与肿瘤

答案: B · 肿瘤溶解综合征：上报，开始心电监护，并预期静脉补液

为什么是这个答案

快速生长的癌症开始治疗后出现高钾、高磷、低钙和尿量减少，提示肿瘤溶解综合征伴 AKI。需要紧急评估、心电监护、静脉补液、治疗高钾血症、按医嘱使用拉布立酶，可能还需要透析。

答案

B · 肿瘤溶解综合征：上报，开始心电监护，并预期静脉补液

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