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

An older patient with dementia is restless at night and keeps trying to get out of bed. Which measure should the nurse try first?

  1. AApply wrist restraints for the rest of the night
  2. BRaise all four bed rails so the patient cannot climb out
  3. CGive a sedative from the as-needed list without first assessing the patient
  4. DCheck for pain, thirst or a full bladder, and offer toileting
2.优先排序与委派困难

A patient with anorexia nervosa is admitted. Which finding is the priority?

  1. AHeart rate 38/min and potassium 2.8 mEq/L
  2. BSays she feels fat although she is very thin
  3. CHas fine, downy hair on her arms
  4. DRefuses to eat in front of other people
3.感染控制与患者安全中等

Which practice makes shift handoff safer?

  1. AGiving handoff in a busy corridor so that the outgoing nurse can leave on time
  2. BUsing a standard format such as SBAR or I-PASS, with time for questions
  3. CGiving handoff from memory without any structure
  4. DLeaving written notes only, without a chance for questions
4.感染控制与患者安全困难

哪项措施最能预防硬膜外输注的给药途径错误？

  1. A患者的所有输注都使用同一类型的泵和输液管
  2. B把所有管路用胶带粘在一起以保持整齐
  3. C硬膜外接口堵塞时改用空闲的静脉接口
  4. D给硬膜外管路做标识，并让其使用专用的输注泵
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 drug improves the accuracy of all dipsticks
  2. BThe color shows severe liver failure is present
  3. CThe color proves blood is present in the urine
  4. DThe dye can interfere with dipstick color readings
6.实验室检查值与电解质困难

A patient on high-dose dexamethasone has a white cell count of 15 × 10³/µL, mostly mature neutrophils with no bands. They have no fever and no signs of infection. What is the most likely explanation?

  1. AA laboratory error, because steroids always lower the white count
  2. BA new leukemia that is confirmed by this result alone
  3. CCertain sepsis that needs antibiotics started without delay
  4. DA steroid effect that moves neutrophils into the circulating blood
7.临床护理中等

一名术后患者心率 125 次/分，血压 88/50 mmHg，敷料被血浸透。发生了什么？

  1. A正常的疼痛反应
  2. B尿路感染引起的感染性休克
  3. C出血导致的低血容量性休克
  4. D只是焦虑
8.临床护理困难

A nurse phones a doctor about a deteriorating patient using SBAR. Which statement belongs in the "R" section?

  1. A"His blood pressure is 85/50 and he is confused."
  2. B"He was admitted three days ago with pneumonia."
  3. C"I am calling about Mr Smith, who is breathless."
  4. D"Please review him within the next 15 minutes."
9.内外科护理：心血管与呼吸中等

一名高血压患者服用氨氯地平。护士最可能观察到哪种副作用？

  1. A踝部肿胀
  2. B高钾血症
  3. C干咳、咽痒
  4. D哮鸣音
10.内外科护理：心血管与呼吸困难

一名已知外周动脉疾病的患者突然出现足部冰冷、苍白、疼痛，没有脉搏，脚趾麻木。优先处理是什么？

  1. A使用加压绷带以改善循环
  2. B鼓励行走以开放侧支循环
  3. C用枕头抬高腿，并用热水袋温暖足部
  4. D立即作为急症上报；保持腿部水平，不加热
11.内外科护理：神经、内分泌与肾脏中等

A kidney transplant recipient asks about travel vaccines. Which statement is correct?

  1. AVaccines will cause the kidney to be rejected
  2. BOnly live vaccines are effective after a transplant
  3. CLive vaccines are usually avoided
  4. DAll vaccines are completely safe after a transplant
12.内外科护理：神经、内分泌与肾脏困难

A patient with an external ventricular drain sat up in bed without help. The drain stayed at its old height, and the drainage bag filled quickly. The patient now has a headache. What is the concern?

  1. AAn infected drain, so the dressing should be removed
  2. BUnderdrainage, so the drain should be lowered further
  3. CNo concern, because more drainage always lowers the ICP safely
  4. DOverdrainage of CSF, so act per protocol and inform the team
13.内外科护理：消化、围手术期与肿瘤中等

Which advice is appropriate for a patient with a very low platelet count?

  1. AFloss hard every day to prevent gum disease
  2. BTake aspirin regularly for headaches
  3. CUse a soft toothbrush and an electric razor
  4. DUse a razor blade for shaving every day
14.内外科护理：消化、围手术期与肿瘤困难

一名长期使用阿片类药物治疗慢性疼痛的患者因手术入院。下列哪项说法正确？

  1. A他们的术后阿片类药物剂量需要比未用过阿片类药物的患者更低
  2. B手术结束后只应给他们对乙酰氨基酚
  3. C继续使用平时的阿片类药物，并因耐受而加用额外镇痛
  4. D入院时应停用所有阿片类药物以防成瘾

3溶液

1.优先排序与委派

答案: D · Check for pain, thirst or a full bladder, and offer toileting

为什么是这个答案

Patients with dementia may not be able to say what they need. Checking for pain, thirst or the need to void often relieves restlessness; restraints, full bed rails and sedation have risks and are not first choices.

答案

D · Check for pain, thirst or a full bladder, and offer toileting
2.优先排序与委派

答案: A · Heart rate 38/min and potassium 2.8 mEq/L

为什么是这个答案

Severe bradycardia and low potassium can cause fatal arrhythmias. The body-image beliefs and eating behaviors matter, but physiological safety comes first.

答案

A · Heart rate 38/min and potassium 2.8 mEq/L
3.感染控制与患者安全

答案: B · Using a standard format such as SBAR or I-PASS, with time for questions

为什么是这个答案

Many errors happen at transitions of care. A structured handoff with an opportunity to ask questions, ideally at the bedside, reduces missed information.

答案

B · Using a standard format such as SBAR or I-PASS, with time for questions
4.感染控制与患者安全

答案: D · 给硬膜外管路做标识，并让其使用专用的输注泵

为什么是这个答案

在连接端给管路贴标识、使用不同（非 Luer）的接头以及单独并有明确标记的泵，可大大减少给药途径连接错误。连接之前应从患者开始沿管路追溯至源头。

答案

D · 给硬膜外管路做标识，并让其使用专用的输注泵
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.核对依据: Urine - abnormal color · MedlinePlus (NIH) (2025)

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 · A steroid effect that moves neutrophils into the circulating blood

为什么是这个答案

Corticosteroids raise the neutrophil count by releasing marginated neutrophils and slowing their exit from the blood, usually without a left shift. The nurse still assesses carefully, because steroids can also hide the usual signs of infection.

答案

D · A steroid effect that moves neutrophils into the circulating blood
7.临床护理

答案: C · 出血导致的低血容量性休克

为什么是这个答案

心动过速、低血压加上可见的失血提示失血性（低血容量性）休克。应压迫止血、紧急呼救，并准备补液或输血。

答案

C · 出血导致的低血容量性休克
8.临床护理

答案: D · "Please review him within the next 15 minutes."

为什么是这个答案

In SBAR, R is the recommendation or request, such as a review within a time frame. The other statements belong to Assessment, Background and Situation.

答案

D · "Please review him within the next 15 minutes."
9.内外科护理：心血管与呼吸

答案: A · 踝部肿胀

为什么是这个答案

氨氯地平等二氢吡啶类钙通道阻滞剂扩张小动脉，使毛细血管压力升高，引起外周水肿、面部潮红和头痛。干咳是 ACE 抑制剂的典型副作用，哮鸣音则见于哮喘患者使用非选择性 β 受体阻滞剂时。

答案

A · 踝部肿胀
10.内外科护理：心血管与呼吸

答案: D · 立即作为急症上报；保持腿部水平，不加热

为什么是这个答案

疼痛（pain）、苍白（pallor）、无脉（pulselessness）、感觉异常（paraesthesia）、麻痹（paralysis）和肢体冰冷（perishingly cold）提示急性肢体缺血，通常由栓子或血栓引起。需要在数小时内重建血运才能保住肢体。加热会增加代谢需求并可造成烫伤，抬高会减少动脉血流，加压则有害。

答案

D · 立即作为急症上报；保持腿部水平，不加热
11.内外科护理：神经、内分泌与肾脏

答案: C · Live vaccines are usually avoided

为什么是这个答案

Live vaccines, such as yellow fever, can cause infection in immunosuppressed patients and are usually avoided. Inactivated vaccines, such as influenza, are recommended, although the response may be weaker.

答案

C · Live vaccines are usually avoided
12.内外科护理：神经、内分泌与肾脏

答案: D · Overdrainage of CSF, so act per protocol and inform the team

为什么是这个答案

When the head rises above the drain level, CSF drains faster. Overdrainage can cause headache, collapse of the ventricles or a subdural bleed. The nurse follows the protocol (often clamping briefly and re-levelling) and informs the neurosurgical team.

答案

D · Overdrainage of CSF, so act per protocol and inform the team
13.内外科护理：消化、围手术期与肿瘤

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

为什么是这个答案

With thrombocytopenia, the nurse reduces bleeding risk: soft toothbrush, electric razor, no NSAIDs or aspirin, avoiding IM injections and rectal procedures, and reporting bleeding, bruising or blood in urine or stool.

答案

C · Use a soft toothbrush and an electric razor
14.内外科护理：消化、围手术期与肿瘤

答案: C · 继续使用平时的阿片类药物，并因耐受而加用额外镇痛

为什么是这个答案

长期使用阿片类药物的患者存在耐受和身体依赖。停用平时的阿片类药物有戒断和疼痛失控的风险。应继续其基础剂量（或转换为其他途径），并加用多模式镇痛；他们往往比未用过阿片类药物的患者需要更多阿片类药物，同时需密切监测。

答案

C · 继续使用平时的阿片类药物，并因耐受而加用额外镇痛

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