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

护士应首先看哪位患者？

  1. A一名新出现言语含糊、面部下垂的患者，30 分钟前开始
  2. B一名长期患类风湿关节炎、有平常晨僵的患者
  3. C一名慢性肾脏病患者，明天要透析
  4. D一名 2 型糖尿病患者，询问饮食问题
2.优先排序与委派困难

After a head injury, a patient has clear fluid dripping from the nose. Which action should the nurse avoid?

  1. AInforming the provider about the drainage
  2. BChecking the fluid for glucose or a halo sign on gauze
  3. CPlacing a loose gauze under the nose
  4. DInserting a tube or suction catheter through the nose
3.感染控制与患者安全中等

A patient is booked for an MRI scan. What must the nurse check beforehand?

  1. AWhether the patient has any metal implants or devices, such as a pacemaker
  2. BWhether the patient’s blood glucose has been in the normal range today
  3. CWhether the patient has eaten a large meal recently
  4. DWhether the patient has had a hearing test this year
4.感染控制与患者安全困难

Shortly after a patient falls, the team holds a brief “post-fall huddle”. What is its main purpose?

  1. ATo complete the patient’s discharge paperwork
  2. BTo decide which staff member was to blame for the fall
  3. CTo agree on what the team will tell the patient’s lawyer and the family
  4. DTo find out quickly why the fall happened and change the care plan to prevent another
5.实验室检查值与电解质中等

为什么肝衰竭患者即使没有服用华法林，INR 也可能升高？

  1. A肝脏合成大多数凝血因子，因此合成减少
  2. B白蛋白是一种凝血因子，其水平下降
  3. C肾脏不再从血液中清除凝血因子
  4. D胆红素直接破坏凝血因子
6.实验室检查值与电解质困难

A patient on clozapine reports a sore throat and fever. The ANC is 400/µL (0.4 × 10⁹/L). What should the nurse do?

  1. AHalve the dose and give it with a throat lozenge
  2. BGive the dose with food to protect the stomach
  3. CHold the clozapine and report the result at once
  4. DGive the next dose and recheck the ANC next month
7.临床护理中等

An arterial blood gas shows a low pH, a high PaCO2 and a normal bicarbonate. What does this show?

  1. ARespiratory acidosis
  2. BMetabolic alkalosis
  3. CMetabolic acidosis
  4. DRespiratory alkalosis
8.临床护理困难

A patient rescued from a house fire has soot around the mouth, singed nasal hairs and a hoarse voice. What is the main concern?

  1. AAirway swelling from inhalation injury
  2. BHypothermia from the fire service water
  3. CA minor throat infection
  4. DDehydration from sweating
9.内外科护理：心血管与呼吸中等

COPD 患者通常推荐接种哪些疫苗？

  1. A仅每年加强一次破伤风疫苗
  2. B完全不接种疫苗，因为已知疫苗会诱发急性加重
  3. C每五年接种一次卡介苗
  4. D每年接种流感疫苗和肺炎球菌疫苗
10.内外科护理：心血管与呼吸困难

During a cardiac arrest, the monitor shows an organised rhythm, but there is no pulse. What should the team do?

  1. AContinue CPR and give adrenaline (epinephrine), as the rhythm is non-shockable
  2. BGive adenosine to slow the rhythm down
  3. CStop CPR, because an organised rhythm on the monitor means recovery
  4. DDeliver an unsynchronised shock at once and then check the pulse
11.内外科护理：神经、内分泌与肾脏中等

头部受伤后，一名患者鼻子里滴出清亮液体。主要的担忧是什么？

  1. A哭泣后产生的正常黏液
  2. B对 CT 造影剂过敏
  3. C颅骨骨折引起的脑脊液漏
  4. D单纯感冒或花粉症发作
12.内外科护理：神经、内分泌与肾脏困难

After a TURP, a patient on bladder irrigation has bladder spasms. The drainage has slowed and contains clots, and the bag holds less than the irrigant given. What should the nurse do first?

  1. AEncourage the patient to strain to pass the clots
  2. BSuspect a clot in the catheter and follow the protocol
  3. CGive an antispasmodic and recheck in four hours
  4. DTurn off the irrigation and leave the catheter alone
13.内外科护理：消化、围手术期与肿瘤中等

Why is a pregnancy test often done before surgery in women who could be pregnant?

  1. APregnant women cannot sign consent forms
  2. BPregnancy always makes surgery impossible
  3. CAnaesthesia, drugs and some tests may harm a fetus
  4. DIt is needed to calculate the anaesthetic drug dose
14.内外科护理：消化、围手术期与肿瘤困难

At the end of an operation, the final count shows one swab missing. What should happen?

  1. AClose the wound, as the swab was probably thrown away
  2. BRecord the count as correct to avoid a delay
  3. CLet the patient leave and search the theatre later
  4. DTell the surgeon, search, and X-ray if it is not found

3溶液

1.优先排序与委派

答案: A · 一名新出现言语含糊、面部下垂的患者，30 分钟前开始

为什么是这个答案

突然言语含糊和面部下垂提示卒中，治疗取决于时间。其他患者的问题是慢性且稳定的，可以等待。

答案

A · 一名新出现言语含糊、面部下垂的患者，30 分钟前开始
2.优先排序与委派

答案: D · Inserting a tube or suction catheter through the nose

为什么是这个答案

Clear nasal drainage after a head injury can be cerebrospinal fluid from a basal skull fracture. Nasal tubes could enter the brain and introduce infection, so they are avoided.

答案

D · Inserting a tube or suction catheter through the nose
3.感染控制与患者安全

答案: A · Whether the patient has any metal implants or devices, such as a pacemaker

为什么是这个答案

The MRI magnet can move or heat metal objects and can stop some implanted devices from working. Patients are screened for implants, pacemakers, metal fragments and metal items such as jewelry before entering the scanner room.

答案

A · Whether the patient has any metal implants or devices, such as a pacemaker
4.感染控制与患者安全

答案: D · To find out quickly why the fall happened and change the care plan to prevent another

为什么是这个答案

A post-fall huddle brings the team together soon after the fall to identify causes such as toileting, medication or footwear and to update the plan. It supports a just culture rather than blame.

答案

D · To find out quickly why the fall happened and change the care plan to prevent another
5.实验室检查值与电解质

答案: A · 肝脏合成大多数凝血因子，因此合成减少

为什么是这个答案

肝脏合成大多数凝血因子，包括依赖维生素 K 的因子。在严重肝病中，它们的合成减少，因此 INR 升高。INR 升高是反映肝衰竭严重程度的指标之一。核对依据: Prothrombin Time Test and INR (PT/INR) · MedlinePlus (NIH) (2024)

答案

A · 肝脏合成大多数凝血因子，因此合成减少
6.实验室检查值与电解质

答案: C · Hold the clozapine and report the result at once

为什么是这个答案

An ANC below 500/µL is severe neutropenia, and with fever and sore throat it suggests a serious infection. Clozapine is held, the provider is told immediately, and infection is assessed and treated. A nurse never changes a dose without a prescription.

答案

C · Hold the clozapine and report the result at once
7.临床护理

答案: A · Respiratory acidosis

为什么是这个答案

A raised PaCO2 with a low pH means the lungs are not removing enough CO2, for example from hypoventilation. A normal bicarbonate suggests it is acute.

答案

A · Respiratory acidosis
8.临床护理

答案: A · Airway swelling from inhalation injury

为什么是这个答案

These signs suggest inhalation injury, which can cause rapid airway swelling and obstruction. Early senior anaesthetic review is needed, as early intubation may be required. Carbon monoxide poisoning must also be considered.

答案

A · Airway swelling from inhalation injury
9.内外科护理：心血管与呼吸

答案: D · 每年接种流感疫苗和肺炎球菌疫苗

为什么是这个答案

接种流感疫苗、肺炎球菌疫苗以及国家免疫规划推荐的其他呼吸道感染疫苗（如新冠疫苗，以及老年人的 RSV 疫苗），可减少 COPD 患者的感染和急性加重。

答案

D · 每年接种流感疫苗和肺炎球菌疫苗
10.内外科护理：心血管与呼吸

答案: A · Continue CPR and give adrenaline (epinephrine), as the rhythm is non-shockable

为什么是这个答案

Pulseless electrical activity is a non-shockable rhythm. Treatment is high-quality CPR, adrenaline as soon as possible and repeated, and a search for reversible causes (the 4 Hs and 4 Ts, such as hypoxia, hypovolaemia, tension pneumothorax and tamponade). Shocks are only for VF and pulseless VT.

答案

A · Continue CPR and give adrenaline (epinephrine), as the rhythm is non-shockable
11.内外科护理：神经、内分泌与肾脏

答案: C · 颅骨骨折引起的脑脊液漏

为什么是这个答案

头部受伤后从鼻子或耳朵流出的清亮液体可能是脑脊液，提示颅底骨折。应上报。告知患者不要擤鼻涕，并避免使用鼻管或吸引。脑脊液漏会增加脑膜炎的风险。

答案

C · 颅骨骨折引起的脑脊液漏
12.内外科护理：神经、内分泌与肾脏

答案: B · Suspect a clot in the catheter and follow the protocol

为什么是这个答案

Clots blocking the catheter make the bladder distend, causing pain and spasms. The nurse checks for kinks, adjusts the irrigation rate per protocol, performs a bladder washout if trained and escalates if not cleared.

答案

B · Suspect a clot in the catheter and follow the protocol
13.内外科护理：消化、围手术期与肿瘤

答案: C · Anaesthesia, drugs and some tests may harm a fetus

为什么是这个答案

Unknown pregnancy can change the decision to operate, the timing, and the choice of drugs and X-rays. Testing is offered with consent, according to local policy.

答案

C · Anaesthesia, drugs and some tests may harm a fetus
14.内外科护理：消化、围手术期与肿瘤

答案: D · Tell the surgeon, search, and X-ray if it is not found

为什么是这个答案

Any discrepancy is reported immediately, the wound is checked before closure, the area and waste are searched, and an X-ray is taken if the item is not found. The event is documented and reported.

答案

D · Tell the surgeon, search, and X-ray if it is not found

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