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

Which infant with gastroenteritis should the nurse see first?

  1. AAlert, crying with tears, had a wet diaper an hour ago
  2. BTwo loose stools today, feeding well
  3. CMild diaper rash, otherwise playful
  4. DLethargic, sunken fontanel, no wet diaper for 8 hours
2.优先排序与委派困难

A patient with septic shock remains hypotensive, with a mean arterial pressure of 58 mmHg, after adequate IV fluids. What should the nurse anticipate?

  1. AA vasopressor, such as norepinephrine, to raise the pressure
  2. BA loop diuretic to remove the extra fluid that has been given
  3. CA beta-blocker to slow the heart rate
  4. DAn oral fluid challenge with a sports drink
3.感染控制与患者安全中等

在给一片药之前，患者说：“这片药和我平时吃的不一样。”护士应怎么做？

  1. A暂停并重新核对医嘱和药物，然后再给药
  2. B给半片药并观察有无异常反应
  3. C告诉患者医院里的药片看起来都不一样
  4. D安慰患者并给药
4.感染控制与患者安全困难

给一名有窒息风险的清醒患者口服药物。哪种做法最安全？

  1. A不检查是否允许就把所有药片碾碎
  2. B让患者仰卧平躺，使吞咽更容易
  3. C让患者坐直，一次给一片药
  4. D为节省时间一次给完所有药片
5.实验室检查值与电解质中等

A patient's potassium is unexpectedly 5.8 mEq/L. The sample was taken after the tourniquet was on for several minutes while the patient pumped their fist. What is the best interpretation?

  1. ATourniquet time affects only the glucose result, not the potassium
  2. BThe result confirms true hyperkalemia and needs no further checking
  3. CThe result may be falsely high and should be repeated with better technique
  4. DFist pumping lowers potassium, so the true level is even higher
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. AHigh potassium, low bicarbonate and low amylase
  2. BHigh calcium, high phosphate and high glucose
  3. CLow sodium, low bicarbonate and high lipase
  4. DLow potassium, high bicarbonate and high amylase
7.临床护理中等

Which equipment must always be kept at the bedside of a patient with a tracheostomy?

  1. AA blood pressure cuff and a spare nasal cannula and oxygen mask only
  2. BA blood glucose meter and a spare urinary catheter of the same size
  3. CSpare tracheostomy tubes, including one a size smaller, and working suction
  4. DA peak flow meter and a nebuliser
8.临床护理困难

一名气管切开患者突然无法呼吸，套管似乎堵塞。第一步该做什么？

  1. A抽空气囊后离开患者
  2. B只经口给氧
  3. C等医生来再做任何处理
  4. D取出内套管，检查是否堵塞
9.内外科护理：心血管与呼吸中等

A peripheral cannula site is red, warm, tender and swollen along the vein. What should the nurse do?

  1. ACover the site and keep using it until it blocks
  2. BLeave it in place, as this is normal after 24 hours
  3. CFlush the cannula hard to clear it
  4. DRemove the cannula, document and monitor the site
10.内外科护理：心血管与呼吸困难

A nurse teaches a patient how to measure blood pressure at home. Which statement shows a need for further teaching?

  1. A"I will sit with my back supported and my arm at heart level."
  2. B"I will rest quietly for five minutes before measuring."
  3. C"I will take two readings and write them both down."
  4. D"I will measure it straight after my morning jog."
11.内外科护理：神经、内分泌与肾脏中等

Where is the zero point of an external ventricular drain usually levelled?

  1. AAt the level of the umbilicus
  2. BAt the tragus of the ear
  3. CAt the mid-axillary line of the chest
  4. DAt the top of the head
12.内外科护理：神经、内分泌与肾脏困难

A nurse teaches a patient about peritoneal dialysis. Which statement shows a need for further teaching?

  1. A"I will weigh myself daily and record my fluid balance."
  2. B"I will check my exit site every day."
  3. C"I will wash my hands carefully before each exchange."
  4. D"If the fluid is cloudy, I'll see if it clears next time."
13.内外科护理：消化、围手术期与肿瘤中等

伤口愈合的哪个阶段涉及肉芽组织和新生血管的形成？

  1. A增殖期
  2. B炎症期
  3. C止血（凝血）期
  4. D成熟期
14.内外科护理：消化、围手术期与肿瘤困难

全身麻醉期间，一名患者出现下颌强直、呼气末 CO₂ 升高和心动过速，随后体温迅速上升。哪种药物是特异性治疗？

  1. A琥珀酰胆碱
  2. B对乙酰氨基酚
  3. C丹曲林
  4. D纳洛酮

3溶液

1.优先排序与委派

答案: D · Lethargic, sunken fontanel, no wet diaper for 8 hours

为什么是这个答案

Lethargy, a sunken fontanel and no urine for hours suggest severe dehydration, which can lead to shock in infants. The other infants are well hydrated.

答案

D · Lethargic, sunken fontanel, no wet diaper for 8 hours
2.优先排序与委派

答案: A · A vasopressor, such as norepinephrine, to raise the pressure

为什么是这个答案

If hypotension continues after fluid resuscitation, a vasopressor such as norepinephrine is started to keep the MAP at least 65 mmHg. Diuretics and beta-blockers would worsen perfusion.

答案

A · A vasopressor, such as norepinephrine, to raise the pressure
3.感染控制与患者安全

答案: A · 暂停并重新核对医嘱和药物，然后再给药

为什么是这个答案

患者的疑虑是一次安全检查。护士应暂停并核对医嘱、药物、剂量和患者，必要时联系药房。有时原因是品牌不同，但必须先加以确认。

答案

A · 暂停并重新核对医嘱和药物，然后再给药
4.感染控制与患者安全

答案: C · 让患者坐直，一次给一片药

为什么是这个答案

直立体位和一次给一种药可降低窒息风险。只有在药房确认安全后才可碾碎，因为一些缓释和肠溶制剂碾碎后会有危险。

答案

C · 让患者坐直，一次给一片药
5.实验室检查值与电解质

答案: C · The result may be falsely high and should be repeated with better technique

为什么是这个答案

Repeated fist clenching and a long tourniquet time release potassium from muscle and can cause hemolysis, both of which give a falsely high potassium. The patient is assessed and the test is repeated with correct technique; true hyperkalemia must not be missed.

答案

C · The result may be falsely high and should be repeated with better technique
6.实验室检查值与电解质

答案: D · 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

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

答案: C · Spare tracheostomy tubes, including one a size smaller, and working suction

为什么是这个答案

Emergency equipment such as spare tubes (same size and one smaller), suction, oxygen and tracheal dilators must be at the bedside. This allows rapid management of a blocked or displaced tube.

答案

C · Spare tracheostomy tubes, including one a size smaller, and working suction
8.临床护理

答案: D · 取出内套管，检查是否堵塞

为什么是这个答案

按急救流程，首先取出内套管、尝试吸痰并呼救。若无效，下一步包括放气囊和更换套管。

答案

D · 取出内套管，检查是否堵塞
9.内外科护理：心血管与呼吸

答案: D · Remove the cannula, document and monitor the site

为什么是这个答案

Redness, pain, warmth and swelling along the vein indicate phlebitis. The cannula is removed, the site is observed for infection and the event is documented. Regular visual phlebitis scoring and removing cannulas that are no longer needed reduce the risk.

答案

D · Remove the cannula, document and monitor the site
10.内外科护理：心血管与呼吸

答案: D · "I will measure it straight after my morning jog."

为什么是这个答案

Home readings should be taken after resting quietly for about 5 minutes, sitting with back supported, feet flat and the arm supported at heart level, with no recent exercise, caffeine or smoking. Two readings are often recorded. Measuring after exercise gives falsely high results.

答案

D · "I will measure it straight after my morning jog."
11.内外科护理：神经、内分泌与肾脏

答案: B · At the tragus of the ear

为什么是这个答案

The EVD is levelled at the tragus, which approximates the foramen of Monro. If the head of the bed is changed, the drain must be re-levelled, because its height decides how much CSF drains.

答案

B · At the tragus of the ear
12.内外科护理：神经、内分泌与肾脏

答案: D · "If the fluid is cloudy, I'll see if it clears next time."

为什么是这个答案

Cloudy effluent may be the first sign of peritonitis and must be reported to the PD unit straight away, keeping the bag for testing. Waiting can allow a serious infection to develop.

答案

D · "If the fluid is cloudy, I'll see if it clears next time."
13.内外科护理：消化、围手术期与肿瘤

答案: A · 增殖期

为什么是这个答案

愈合有四个相互重叠的阶段：止血、炎症、增殖（肉芽组织、血管生成和上皮化）和成熟（胶原重塑，可持续一年或更久）。

答案

A · 增殖期
14.内外科护理：消化、围手术期与肿瘤

答案: C · 丹曲林

为什么是这个答案

恶性高热的治疗包括停用触发药物、用 100% 氧气过度通气、静脉给予丹曲林（减少肌质网钙释放）、主动降温，以及治疗高钾血症和心律失常。琥珀酰胆碱是触发因素。

答案

C · 丹曲林

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