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

对于采取防跌倒措施的患者，护士应将哪项任务委派给护理助理？

  1. A教家属如何在家中预防跌倒
  2. B按计划每 2 小时协助患者上厕所
  3. C决定是否仍需要床边警报器
  4. D每天早晨评估并记录患者的跌倒风险评分
2.优先排序与委派困难

During an infusion of a thrombolytic drug for stroke, the patient develops a severe headache and starts vomiting. What should the nurse do first?

  1. AContinue the infusion, because headache is expected
  2. BGive a dose of aspirin for the headache
  3. CStop the infusion and inform the provider at once
  4. DSlow the infusion and give an antiemetic as prescribed
3.感染控制与患者安全中等

An order uses the abbreviation “MS”. Why is this unsafe?

  1. AIt is reserved for drugs used in multiple sclerosis
  2. BIt means the drug must be given by mouth only
  3. CIt is the abbreviation for milliseconds, not a drug
  4. DIt can mean either morphine sulfate or magnesium sulfate
4.感染控制与患者安全困难

急诊候诊室里的一名患者咳嗽六周，伴盗汗、体重减轻和痰中带血。护士首先应做什么？

  1. A请患者在候诊室等候叫号
  2. B给患者戴上口罩，并转入空气传播隔离病房
  3. C开始接触传播预防，工作人员穿隔离衣、戴手套
  4. D把患者安置在共用的隔间里并拉上床帘
5.实验室检查值与电解质中等

A urine culture is ordered for a patient with an indwelling urinary catheter. How should the nurse collect the sample?

  1. ARemove the catheter and culture the catheter tip
  2. BAspirate from the sampling port with a sterile syringe
  3. CDisconnect the catheter from the tubing and let it drain
  4. DPour urine from the drainage bag into a sterile cup
6.实验室检查值与电解质困难

A young woman with frequent self-induced vomiting has swollen salivary glands. Which laboratory pattern is most likely?

  1. ALow potassium, high bicarbonate and high amylase
  2. BLow sodium, low bicarbonate and high lipase
  3. CHigh calcium, high phosphate and high glucose
  4. DHigh potassium, low bicarbonate and low amylase
7.临床护理中等

一名化疗后中性粒细胞减少的患者体温为 38.3 °C。首要措施是什么？

  1. A等 24 小时看发热是否消退
  2. B鼓励患者出去散步
  3. C只给对乙酰氨基酚，明天再次复查体温
  4. D按中性粒细胞减少性脓毒症处理，紧急静脉使用抗生素
8.临床护理困难

A patient with lung cancer develops swelling of the face and arms, distended neck veins and breathlessness that is worse lying down. What should be suspected?

  1. AHypothyroidism
  2. BRight-sided heart failure from valve disease
  3. CAn allergic reaction to food
  4. DSuperior vena cava obstruction
9.内外科护理：心血管与呼吸中等

Rheumatic heart disease most often follows which infection?

  1. AA group A streptococcal throat infection
  2. BStaphylococcal infection of the skin
  3. CA fungal infection of the lungs
  4. DA viral infection of the upper airway
10.内外科护理：心血管与呼吸困难

A patient with COPD who is known to retain CO₂ arrives on 15 L/min oxygen. They are now drowsy with SpO₂ 99%. What is the most appropriate action?

  1. AKeep the oxygen at 15 L/min because the saturation is excellent
  2. BGive a sedative to help the patient rest
  3. CRemove the oxygen completely and observe
  4. DReduce the oxygen to aim for 88–92% and get a blood gas
11.内外科护理：神经、内分泌与肾脏中等

甲状腺切除术后，为什么常在床边备有拆线或拆夹器？

  1. A颈部血肿可压迫气道，可能需要松解
  2. B用于从颈静脉抽血
  3. C用于在引流管不通时调整引流管
  4. D必须在术后第一天晚上拆线
12.内外科护理：神经、内分泌与肾脏困难

On day 6 after a subarachnoid haemorrhage, a patient becomes newly confused and develops weakness in one arm. The aneurysm was secured on day 1. What is the most likely cause?

  1. AHypoglycaemia from reduced eating
  2. BDelayed cerebral ischaemia from vasospasm
  3. CNormal tiredness after major surgery
  4. DRe-bleeding from the secured aneurysm
13.内外科护理：消化、围手术期与肿瘤中等

Why is IV hydration given with cisplatin?

  1. ATo raise the blood pressure during treatment
  2. BTo protect the kidneys from damage
  3. CTo make the drug less effective
  4. DTo prevent hair loss
14.内外科护理：消化、围手术期与肿瘤困难

A sacral wound has heavy exudate, and the surrounding skin is white, soft and wrinkled. What should the nurse do?

  1. AUse a dressing that adds even more moisture
  2. BLeave the same dressing in place for a week so the wound is not disturbed
  3. CApply a tight plastic film directly over the wound
  4. DProtect the skin edges and use a more absorbent dressing

3溶液

1.优先排序与委派

答案: B · 按计划每 2 小时协助患者上厕所

为什么是这个答案

定时如厕巡视是遵循护理计划的常规任务。跌倒风险评分、决定干预措施和教育都需要护理判断。

答案

B · 按计划每 2 小时协助患者上厕所
2.优先排序与委派

答案: C · Stop the infusion and inform the provider at once

为什么是这个答案

A new severe headache, vomiting or neurological decline during thrombolysis can mean intracranial bleeding. The infusion is stopped, the provider informed and an urgent scan arranged.

答案

C · Stop the infusion and inform the provider at once
3.感染控制与患者安全

答案: D · It can mean either morphine sulfate or magnesium sulfate

为什么是这个答案

“MS”, “MSO4” and “MgSO4” can be confused, and giving one drug instead of the other can cause serious harm. Drug names are written in full.

答案

D · It can mean either morphine sulfate or magnesium sulfate
4.感染控制与患者安全

答案: B · 给患者戴上口罩，并转入空气传播隔离病房

为什么是这个答案

咳嗽持续时间长、盗汗、体重减轻和咯血提示肺结核。患者应佩戴外科口罩并迅速转入负压病房，工作人员佩戴呼吸器。床帘不能阻挡经空气传播的颗粒。

答案

B · 给患者戴上口罩，并转入空气传播隔离病房
5.实验室检查值与电解质

答案: B · Aspirate from the sampling port with a sterile syringe

为什么是这个答案

The catheter sampling port is cleaned and urine is aspirated with a sterile syringe, keeping the system closed. Urine in the drainage bag has been standing and can contain bacteria that multiplied there; opening the system raises the risk of infection.

答案

B · Aspirate from the sampling port with a sterile syringe
6.实验室检查值与电解质

答案: A · Low potassium, high bicarbonate and high amylase

为什么是这个答案

Repeated vomiting causes hypokalemia and metabolic alkalosis (high bicarbonate) from the loss of stomach acid. Enlarged salivary glands can raise salivary amylase. Hypokalemia can cause dangerous arrhythmias, so it is monitored and corrected.

答案

A · Low potassium, high bicarbonate and high amylase
7.临床护理

答案: D · 按中性粒细胞减少性脓毒症处理，紧急静脉使用抗生素

为什么是这个答案

中性粒细胞减少性脓毒症是肿瘤急症。应在一小时内静脉给予广谱抗生素，无须等待检查结果。

答案

D · 按中性粒细胞减少性脓毒症处理，紧急静脉使用抗生素
8.临床护理

答案: D · Superior vena cava obstruction

为什么是这个答案

Superior vena cava obstruction prevents venous drainage from the head and arms. It is an oncological emergency; patients are positioned upright and need urgent specialist treatment.

答案

D · Superior vena cava obstruction
9.内外科护理：心血管与呼吸

答案: A · A group A streptococcal throat infection

为什么是这个答案

Rheumatic fever is an autoimmune reaction weeks after group A streptococcal pharyngitis. It can permanently damage heart valves, most often the mitral valve. Prompt antibiotic treatment of strep throat prevents it.

答案

A · A group A streptococcal throat infection
10.内外科护理：心血管与呼吸

答案: D · Reduce the oxygen to aim for 88–92% and get a blood gas

为什么是这个答案

In patients at risk of hypercapnic respiratory failure, excess oxygen can raise PaCO₂ and cause drowsiness and acidosis. Oxygen is stepped down to a target of 88–92% (for example via a Venturi mask), not stopped abruptly, which could cause dangerous hypoxaemia. An arterial blood gas guides further treatment, which may include NIV.

答案

D · Reduce the oxygen to aim for 88–92% and get a blood gas
11.内外科护理：神经、内分泌与肾脏

答案: A · 颈部血肿可压迫气道，可能需要松解

为什么是这个答案

甲状腺手术后颈部血肿可迅速压迫气道。许多病房在床边备有拆夹器或拆线器及气道设备，以便在紧急情况下打开伤口。护士应观察有无肿胀、喘鸣和呼吸困难。

答案

A · 颈部血肿可压迫气道，可能需要松解
12.内外科护理：神经、内分泌与肾脏

答案: B · Delayed cerebral ischaemia from vasospasm

为什么是这个答案

Vasospasm of cerebral arteries typically occurs several days after a subarachnoid haemorrhage and causes new focal deficits or confusion. It needs urgent medical review. Normal fluid balance is maintained, and nimodipine is continued.

答案

B · Delayed cerebral ischaemia from vasospasm
13.内外科护理：消化、围手术期与肿瘤

答案: B · To protect the kidneys from damage

为什么是这个答案

Cisplatin is nephrotoxic, so hydration and electrolyte replacement (especially magnesium) are given. It can also cause ototoxicity, neuropathy and severe nausea.

答案

B · To protect the kidneys from damage
14.内外科护理：消化、围手术期与肿瘤

答案: D · Protect the skin edges and use a more absorbent dressing

为什么是这个答案

Maceration shows that exudate is not being managed. A barrier film or cream protects the surrounding skin, and a more absorbent dressing or more frequent changes are used. The cause of high exudate is reviewed.

答案

D · Protect the skin edges and use a more absorbent dressing

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