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

Before giving a scheduled dose of metoprolol, which assessment is most important?

  1. ABlood glucose and weight
  2. BTemperature and the latest pain score
  3. CApical pulse and blood pressure
  4. DBowel sounds and urine color
2.优先排序与委派困难

A patient suddenly has severe pain in one leg. The leg is pale and cold with no pedal pulse. What does this suggest?

  1. AAcute arterial occlusion, which is an emergency
  2. BChronic venous insufficiency that needs elevation
  3. CA deep vein thrombosis that can be treated next week
  4. DA muscle cramp that will pass with stretching
3.感染控制与患者安全中等

A newly hired nurse had BCG vaccine as a child. Which TB screening test is usually preferred?

  1. AA chest x-ray every month for the first year
  2. BNo screening, because BCG prevents all TB
  3. CA tuberculin skin test, which is read 24 hours after it is placed
  4. DAn interferon-gamma release assay (IGRA) blood test
4.感染控制与患者安全困难

Minutes after the first IV dose of an antibiotic starts, the patient develops wheezing, hives and low blood pressure. What should the nurse do first?

  1. AGive an oral antihistamine
  2. BRecord the new allergy in the chart
  3. CSlow the infusion rate
  4. DStop the infusion
5.实验室检查值与电解质中等

During a red cell transfusion, when are serious acute reactions most likely, so the nurse stays with the patient?

  1. AAfter the last drop is given
  2. BIn the first 15 minutes
  3. CAfter about 2 hours
  4. DThe next morning
6.实验室检查值与电解质困难

Two weeks after a sore throat, a child develops dark (cola-colored) urine, puffy eyes and high blood pressure. Urinalysis shows red cell casts and protein. Which condition is most likely?

  1. APrerenal acute kidney injury
  2. BLower urinary tract infection (cystitis)
  3. CPost-streptococcal glomerulonephritis
  4. DKidney stone in the ureter
7.临床护理中等

How does CPAP help a patient with obstructive sleep apnoea?

  1. AIt delivers bronchodilator drugs deep into the lungs overnight
  2. BIt removes excess carbon dioxide from the lungs by gentle suction
  3. CIt strengthens the breathing muscles during the day
  4. DIt keeps the upper airway open during sleep with continuous air pressure
8.临床护理困难

术后患者出现哪项表现最强烈提示肺栓塞？

  1. A脉搏缓慢伴血压升高
  2. B突发气促和胸膜性胸痛，伴心动过速
  3. C使用沙丁胺醇后好转的哮鸣
  4. D一周内逐渐出现的咳嗽伴黄痰和轻度发热
9.内外科护理：心血管与呼吸中等

A patient is going home with a 24-hour Holter monitor. Which instruction is most important?

  1. AShower as normal with the monitor on
  2. BStay in bed for the full 24 hours so the trace is clear
  3. CRemove the monitor whenever symptoms occur and restart it
  4. DKeep a diary of symptoms and activities with the times
10.内外科护理：心血管与呼吸困难

A nurse teaches a patient with heart failure who takes ramipril and spironolactone. Which statement shows a need for further teaching?

  1. A"I will weigh myself every morning after I go to the toilet."
  2. B"I will avoid ibuprofen for my joint pain."
  3. C"I will use a salt substitute instead of ordinary salt."
  4. D"I will call if I gain weight quickly or get more breathless."
11.内外科护理：神经、内分泌与肾脏中等

Which statement about the PSA blood test is correct?

  1. AA raised result always means prostate cancer
  2. BIt is only raised in women with bladder cancer
  3. CA normal result always rules out any prostate cancer
  4. DIt can be raised by benign problems as well as by cancer
12.内外科护理：神经、内分泌与肾脏困难

全甲状腺切除术后，一名患者焦虑，出现喘鸣和颈部紧张性肿胀。护士首先应做什么？

  1. A在颈部放冰袋，让患者平躺
  2. B呼叫紧急援助：血肿可能压迫气道
  3. C让患者尽可能多说话，以测试声音
  4. D给予镇痛，一小时后再评估肿胀
13.内外科护理：消化、围手术期与肿瘤中等

Why does a patient need lifelong vitamin B12 injections after total gastrectomy?

  1. AIntrinsic factor from the stomach is no longer made
  2. BThe small bowel stops absorbing all nutrients
  3. CThe liver can no longer store any vitamins
  4. DVitamin B12 is lost in the urine after the surgery
14.内外科护理：消化、围手术期与肿瘤困难

Why is folinic acid (leucovorin) given after high-dose methotrexate?

  1. ATo rescue normal cells from methotrexate toxicity
  2. BTo prevent hair loss during treatment
  3. CTo treat the patient's anaemia only
  4. DTo increase the anticancer effect on the tumour

3溶液

1.优先排序与委派

答案: C · Apical pulse and blood pressure

为什么是这个答案

Metoprolol can cause bradycardia and hypotension, so the nurse checks the apical pulse and blood pressure first. The dose is held and reported according to the prescribed parameters.

答案

C · Apical pulse and blood pressure
2.优先排序与委派

答案: A · Acute arterial occlusion, which is an emergency

为什么是这个答案

Sudden pain, pallor, coldness and loss of pulse suggest an embolus blocking an artery. The limb can be lost within hours, so the nurse escalates immediately.

答案

A · Acute arterial occlusion, which is an emergency
3.感染控制与患者安全

答案: D · An interferon-gamma release assay (IGRA) blood test

为什么是这个答案

BCG vaccine can cause a false-positive tuberculin skin test. IGRA blood tests are not affected by BCG, so they are preferred for people who have had the vaccine.

答案

D · An interferon-gamma release assay (IGRA) blood test
4.感染控制与患者安全

答案: D · Stop the infusion

为什么是这个答案

These are signs of anaphylaxis. The nurse stops the infusion at once, calls for help and supports the airway, and intramuscular epinephrine (adrenaline) is the first-line treatment. Documentation comes later.

答案

D · Stop the infusion
5.实验室检查值与电解质

答案: B · In the first 15 minutes

为什么是这个答案

Acute hemolytic and anaphylactic reactions usually appear early, so the transfusion is started slowly and the nurse stays with the patient for about the first 15 minutes, checking vital signs before, during and after according to policy.

答案

B · In the first 15 minutes
6.实验室检查值与电解质

答案: C · Post-streptococcal glomerulonephritis

为什么是这个答案

Red cell casts show bleeding from the glomeruli, which is typical of glomerulonephritis. After a streptococcal infection, immune complexes inflame the glomeruli, causing hematuria, proteinuria, edema and hypertension. Cystitis and stones do not cause red cell casts.核对依据: Strep A Test · MedlinePlus (NIH) (2024)

答案

C · Post-streptococcal glomerulonephritis
7.临床护理

答案: D · It keeps the upper airway open during sleep with continuous air pressure

为什么是这个答案

Continuous positive airway pressure acts as a splint for the upper airway, preventing collapse and apnoeas. Patients should bring their CPAP machine into hospital.

答案

D · It keeps the upper airway open during sleep with continuous air pressure
8.临床护理

答案: B · 突发气促和胸膜性胸痛，伴心动过速

为什么是这个答案

肺栓塞通常表现为突发呼吸困难、呼吸时胸痛、心动过速、血氧饱和度下降，有时伴咯血或晕厥。

答案

B · 突发气促和胸膜性胸痛，伴心动过速
9.内外科护理：心血管与呼吸

答案: D · Keep a diary of symptoms and activities with the times

为什么是这个答案

A Holter monitor records the ECG continuously during normal daily life. A diary of symptoms and activities lets the reviewer match symptoms such as palpitations or dizziness to the rhythm. The device is kept dry unless it is designed to be waterproof.

答案

D · Keep a diary of symptoms and activities with the times
10.内外科护理：心血管与呼吸

答案: C · "I will use a salt substitute instead of ordinary salt."

为什么是这个答案

Many salt substitutes contain potassium chloride. With an ACE inhibitor and spironolactone, both of which raise potassium, they can cause dangerous hyperkalaemia. Daily weights, reporting rapid weight gain and avoiding NSAIDs (which cause fluid retention) are correct.

答案

C · "I will use a salt substitute instead of ordinary salt."
11.内外科护理：神经、内分泌与肾脏

答案: D · It can be raised by benign problems as well as by cancer

为什么是这个答案

PSA can rise with BPH, prostatitis, UTI, recent ejaculation or instrumentation, as well as cancer. A normal level does not exclude cancer. Results are interpreted with symptoms, examination and other tests.

答案

D · It can be raised by benign problems as well as by cancer
12.内外科护理：神经、内分泌与肾脏

答案: B · 呼叫紧急援助：血肿可能压迫气道

为什么是这个答案

伴有喘鸣的迅速增大的颈部血肿是气道急症。应呼叫紧急援助；在许多病房，会在床边拆除夹子或缝线以松解血肿（遵循当地急救程序），然后再进行确定性的气道管理和手术。

答案

B · 呼叫紧急援助：血肿可能压迫气道
13.内外科护理：消化、围手术期与肿瘤

答案: A · Intrinsic factor from the stomach is no longer made

为什么是这个答案

Parietal cells of the stomach make intrinsic factor, which is needed for B12 absorption in the terminal ileum. Without it, pernicious-type anaemia and neuropathy develop unless B12 is given by injection.

答案

A · Intrinsic factor from the stomach is no longer made
14.内外科护理：消化、围手术期与肿瘤

答案: A · To rescue normal cells from methotrexate toxicity

为什么是这个答案

Methotrexate inhibits dihydrofolate reductase. Timed folinic acid bypasses this block in normal cells, reducing toxicity such as mucositis and myelosuppression, while methotrexate levels and kidney function are monitored.

答案

A · To rescue normal cells from methotrexate toxicity

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