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 patient’s urinary catheter has drained no urine for two hours, and the lower abdomen is swollen. What should the nurse do first?

  1. ACheck the tubing for kinks or obstruction
  2. BGive a prescribed diuretic straight away
  3. CRemove the catheter and wait for the patient to void
  4. DEncourage the patient to drink more water
2.优先排序与委派困难

A nurse returns to the station to find four messages. Which one is answered first?

  1. AA colleague asks to swap shifts with them next week because of a family wedding
  2. BA family member wants an update on their father’s progress
  3. CThe laboratory is calling with a critical potassium result of 2.6 mEq/L
  4. DThe pharmacy asks when the next delivery should be scheduled
3.感染控制与患者安全中等

A patient is on seizure precautions. Which equipment should be ready at the bedside?

  1. AWorking suction and oxygen equipment
  2. BRestraints ready for all four limbs
  3. CA tongue blade to put between the teeth
  4. DAn ice pack to place on the forehead
4.感染控制与患者安全困难

Several patients arrive with suspected inhalational anthrax after a deliberate release. Which precautions are needed for their care?

  1. AContact precautions with gowns and gloves
  2. BDroplet precautions with surgical masks
  3. CStandard precautions, because it is not spread from person to person
  4. DAirborne precautions in negative-pressure rooms, because spores are inhaled
5.实验室检查值与电解质中等

A patient with diabetes is found unconscious with a blood glucose of 38 mg/dL (2.1 mmol/L). Which treatment is appropriate?

  1. AGlucose tablets placed between the patient's teeth
  2. BA dose of rapid-acting insulin to stabilize the glucose
  3. CGlucagon by injection, or IV dextrose as prescribed
  4. DOrange juice poured slowly into the patient's mouth
6.实验室检查值与电解质困难

一名服用地高辛的患者血药水平为 1.2 ng/mL，钾 2.8 mEq/L，新出现频发室性早搏。最好的解释是什么？

  1. A钾对心律没有影响
  2. B地高辛不可能是原因，因为水平在通常范围内
  3. C可能存在中毒，因为低钾会增强地高辛的作用
  4. D患者需要更高剂量的地高辛来控制心律
7.临床护理中等

Which side effect is common when a patient starts taking metformin?

  1. ASevere headache
  2. BHypoglycaemia in most patients who take it
  3. CNausea, abdominal discomfort or diarrhoea
  4. DRapid weight gain
8.临床护理困难

A patient with severe sepsis starts bleeding from cannula sites and the gums, with a low platelet count and prolonged clotting times. What is most likely?

  1. AVitamin C deficiency
  2. BDisseminated intravascular coagulation
  3. CAn allergic reaction to the cannula
  4. DHaemophilia A
9.内外科护理：心血管与呼吸中等

During an episode of chest pain, a patient's ECG shows new horizontal ST depression. What does this most likely indicate?

  1. APericarditis
  2. BHyperkalaemia
  3. CMyocardial ischaemia
  4. DA normal finding during pain
10.内外科护理：心血管与呼吸困难

A ventilated patient with severe ARDS is to be turned prone. What is the main reason, and the key nursing risk?

  1. AIt improves oxygenation; risks are pressure injury and tube displacement
  2. BIt improves digestion and gut motility; the main risk is constipation
  3. CIt lowers the blood pressure; the main risk is rebound hypertension
  4. DIt treats infection; the risk is fever
11.内外科护理：神经、内分泌与肾脏中等

一名 SIADH 患者血钠 126 mmol/L，症状轻微。通常的一线治疗是什么？

  1. A静脉输注 5% 葡萄糖
  2. B去氨加压素
  3. C限制液体
  4. D额外口服水
12.内外科护理：神经、内分泌与肾脏困难

对血液透析患者，哪个用药时间问题很重要？

  1. A透析日不能服用任何药物
  2. B透析不会清除任何药物
  3. C所有药物都必须在透析前不久给予
  4. D可被透析清除的药物可能需要在透析后给予
13.内外科护理：消化、围手术期与肿瘤中等

Which is a recognised cause of anaphylaxis during surgery?

  1. AA warmed blanket
  2. BSterile normal saline
  3. CChlorhexidine skin preparation
  4. DThe patient's own blood from cell salvage
14.内外科护理：消化、围手术期与肿瘤困难

一名两个月前放置了冠状动脉支架、服用阿司匹林和氯吡格雷的患者出现黑便，现在情况稳定。对抗血小板药物，最恰当的处理是什么？

  1. A两种药物原样继续，并且不向团队提及出血
  2. B报告出血；由团队在心脏科的参与下决定，权衡出血与支架血栓
  3. C将两种药物的剂量加倍，因为出血意味着支架有更大的血栓风险
  4. D永久停用两种药物，因为任何出血都意味着它们不再安全

3溶液

1.优先排序与委派

答案: A · Check the tubing for kinks or obstruction

为什么是这个答案

Sudden lack of drainage with a full bladder usually means a kinked or blocked catheter. The nurse checks the tubing and position first, then follows the policy for irrigation or replacement.

答案

A · Check the tubing for kinks or obstruction
2.优先排序与委派

答案: C · The laboratory is calling with a critical potassium result of 2.6 mEq/L

为什么是这个答案

A critical potassium of 2.6 mEq/L can cause life-threatening arrhythmias, so it is acted on first: the nurse assesses the patient and informs the provider. The other calls can wait.

答案

C · The laboratory is calling with a critical potassium result of 2.6 mEq/L
3.感染控制与患者安全

答案: A · Working suction and oxygen equipment

为什么是这个答案

Suction and oxygen are kept ready to manage secretions and support breathing during or after a seizure. Nothing is put in the mouth, and restraints are not used because they can cause injury.

答案

A · Working suction and oxygen equipment
4.感染控制与患者安全

答案: C · Standard precautions, because it is not spread from person to person

为什么是这个答案

Inhalational anthrax is caught by breathing in spores from the environment and does not spread from person to person, so standard precautions are enough. Decontamination may still be needed for people with spores on their skin or clothing.

答案

C · Standard precautions, because it is not spread from person to person
5.实验室检查值与电解质

答案: C · Glucagon by injection, or IV dextrose as prescribed

为什么是这个答案

A patient who cannot swallow safely must not receive anything by mouth because of the risk of aspiration. Glucagon (injected or intranasal) or IV dextrose raises the glucose; once awake and able to swallow, the patient is given oral carbohydrate and a snack.核对依据: Hypoglycemia · MedlinePlus (NIH); Low blood sugar · MedlinePlus (NIH) (2026)

答案

C · Glucagon by injection, or IV dextrose as prescribed
6.实验室检查值与电解质

答案: C · 可能存在中毒，因为低钾会增强地高辛的作用

为什么是这个答案

低钾增加地高辛与心肌细胞的结合，因此在正常水平也可发生中毒。护士应暂停该剂量，报告结果并预期补钾。核对依据: Low blood potassium · MedlinePlus (NIH) (2025)

答案

C · 可能存在中毒，因为低钾会增强地高辛的作用
7.临床护理

答案: C · Nausea, abdominal discomfort or diarrhoea

为什么是这个答案

Gastrointestinal upset is common at the start, so metformin is started at a low dose with food and increased gradually. It rarely causes hypoglycaemia when used alone.

答案

C · Nausea, abdominal discomfort or diarrhoea
8.临床护理

答案: B · Disseminated intravascular coagulation

为什么是这个答案

In DIC, widespread activation of clotting consumes platelets and clotting factors, causing both small clots and bleeding. Treating the underlying cause and replacing blood products as needed are key.

答案

B · Disseminated intravascular coagulation
9.内外科护理：心血管与呼吸

答案: C · Myocardial ischaemia

为什么是这个答案

New horizontal or downsloping ST depression during pain suggests myocardial ischaemia, as in unstable angina or NSTEMI. It should be reported immediately with serial ECGs and troponins. ST depression can also reflect reciprocal change opposite a STEMI.

答案

C · Myocardial ischaemia
10.内外科护理：心血管与呼吸

答案: A · It improves oxygenation; risks are pressure injury and tube displacement

为什么是这个答案

Prone positioning improves ventilation–perfusion matching and oxygenation and improves survival in severe ARDS. Turning needs a trained team. Risks include accidental extubation or line removal and pressure damage to the face, chest and knees, so careful positioning and skin checks are essential.

答案

A · It improves oxygenation; risks are pressure injury and tube displacement
11.内外科护理：神经、内分泌与肾脏

答案: C · 限制液体

为什么是这个答案

在 SIADH 中，机体潴留水分。对轻至中度病例，一线治疗是限制液体，并治疗病因。低渗液体和去氨加压素会使血钠进一步降低。严重症状（惊厥、意识下降）需要在监护环境下使用高渗盐水。

答案

C · 限制液体
12.内外科护理：神经、内分泌与肾脏

答案: D · 可被透析清除的药物可能需要在透析后给予

为什么是这个答案

可透析的药物（如某些抗生素）可在透析后给予，以免被清除。对透析前的降压药，常为避免低血压而暂停。用药时间由开处方者和药师确定。

答案

D · 可被透析清除的药物可能需要在透析后给予
13.内外科护理：消化、围手术期与肿瘤

答案: C · Chlorhexidine skin preparation

为什么是这个答案

Common causes of perioperative anaphylaxis include neuromuscular blockers, antibiotics, chlorhexidine and latex. Allergies are documented, and suspected reactions are investigated afterwards.

答案

C · Chlorhexidine skin preparation
14.内外科护理：消化、围手术期与肿瘤

答案: B · 报告出血；由团队在心脏科的参与下决定，权衡出血与支架血栓

为什么是这个答案

冠状动脉支架置入后早期，停用双联抗血小板治疗有很高的支架血栓和心肌梗死风险，而继续使用则增加出血。决定由医疗团队作出，最好有心脏科和消化科参与；常继续阿司匹林，第二种药物则根据出血严重程度和内镜所见短暂暂停或继续使用。

答案

B · 报告出血；由团队在心脏科的参与下决定，权衡出血与支架血栓

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