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 taking lisinopril develops swelling of the lips and tongue. What should the nurse do first?

  1. AAssess the airway and call for urgent help
  2. BGive the next dose of lisinopril with water
  3. CApply a cold pack and recheck in an hour
  4. DTell the patient this is a common, harmless effect
2.优先排序与委派困难

A patient receiving comfort-focused end-of-life care is distressed by breathlessness. Which approach is most appropriate?

  1. AWithhold all opioids because they may slow breathing
  2. BLeave the patient alone so they can rest
  3. CStart a series of aggressive tests to find the exact cause of the breathlessness
  4. DGive prescribed opioids and use positioning and a fan to relieve breathlessness
3.感染控制与患者安全中等

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

  1. AIt means the drug must be given by mouth only
  2. BIt is reserved for drugs used in multiple sclerosis
  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

Over a few hours, the emergency department sees many previously healthy people with the same unusual severe symptoms. What should the nurse do?

  1. AReport it to infection prevention and public health authorities promptly
  2. BTell only the patients’ families about the pattern
  3. CSend the patients home quickly to avoid crowding the emergency department
  4. DTreat each patient and wait to see if more arrive next week
5.实验室检查值与电解质中等

哪个因素最可能使患者的血锂水平升高？

  1. A在炎热天气比平时多喝液体
  2. B每次随餐服药而不是餐前服药
  3. C连续几天比平时多吃盐
  4. D脱水或钠摄入突然减少
6.实验室检查值与电解质困难

静脉输注硫酸镁期间，哪项评估最能早期发现中毒？

  1. A每小时血糖和瞳孔大小
  2. B每小时皮肤颜色和毛细血管再充盈
  3. C肠鸣音和腹围
  4. D膝反射、呼吸频率和尿量
7.临床护理中等

A patient is started on spironolactone while already taking an ACE inhibitor. Which blood result should be watched most closely?

  1. AGlucose, because both drugs cause hyperglycaemia
  2. BCalcium, because both drugs lower it
  3. CSodium, because both drugs raise it sharply
  4. DPotassium, because both drugs can raise it
8.临床护理困难

A patient has a swollen, warm, tender calf on one side. Which action should the nurse avoid?

  1. AChecking whether VTE prophylaxis was given
  2. BMassaging the calf
  3. CMeasuring and comparing calf circumference
  4. DReporting the findings to the doctor
9.内外科护理：心血管与呼吸中等

Which history is a contraindication to thrombolysis for a STEMI?

  1. AA previous haemorrhagic stroke
  2. BA previous appendicectomy many years ago
  3. CMild asthma controlled with inhalers
  4. DTreated high blood pressure
10.内外科护理：心血管与呼吸困难

After a fall onto the chest, part of a patient's chest wall moves inward when they breathe in and outward when they breathe out. What does this indicate?

  1. ANormal chest movement caused by pain on breathing
  2. BA single simple rib fracture with no lung injury
  3. CA flail chest from ribs broken in more than one place
  4. DA large pleural effusion pressing on the chest wall
11.内外科护理：神经、内分泌与肾脏中等

A nurse is teaching a patient going home after a mild concussion. Which statement shows a need for further teaching?

  1. A"A few drinks tonight will help me relax and sleep."
  2. B"I will come back if I start vomiting again and again."
  3. C"Someone will stay with me for the first night."
  4. D"I will return if my headache gets steadily worse."
12.内外科护理：神经、内分泌与肾脏困难

An 89-year-old with stage 5 CKD and severe heart failure, who has capacity, decides not to start dialysis. What is the nurse's best response?

  1. AStop all care, because nothing more can be done
  2. BTell the patient they must start dialysis by law
  3. CAsk the family to change the patient's mind
  4. DRespect the decision and support symptom-focused care
13.内外科护理：消化、围手术期与肿瘤中等

许多化疗药物给药后，对体液采取特殊预防措施通常要持续多长时间？

  1. A通常约 48 小时
  2. B仅在输注期间
  3. C从不需要
  4. D整整一年
14.内外科护理：消化、围手术期与肿瘤困难

A patient with a sacral pressure ulcer keeps sliding down the bed when the head is raised high. Which advice best reduces shear?

  1. ASit the patient upright without any support for the feet
  2. BKeep the head of the bed at or below 30° if possible; use slide sheets
  3. CUse a dry sheet and drag the patient up the bed
  4. DRaise the head of the bed to 90° and pull the patient up the bed by the arms

3溶液

1.优先排序与委派

答案: A · Assess the airway and call for urgent help

为什么是这个答案

Angioedema is a rare but dangerous effect of ACE inhibitors. The airway comes first: the nurse assesses breathing, calls for urgent help and holds the drug.

答案

A · Assess the airway and call for urgent help
2.优先排序与委派

答案: D · Give prescribed opioids and use positioning and a fan to relieve breathlessness

为什么是这个答案

In palliative care, opioids are used to relieve breathlessness, along with positioning, a fan and calm reassurance. The aim is comfort, not more investigations.

答案

D · Give prescribed opioids and use positioning and a fan to relieve breathlessness
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: A · Report it to infection prevention and public health authorities promptly

为什么是这个答案

Clusters of similar unusual illness can signal an outbreak or bioterrorism. Early reporting allows public health to investigate, guide precautions and treatment, and protect the community.

答案

A · Report it to infection prevention and public health authorities promptly
5.实验室检查值与电解质

答案: D · 脱水或钠摄入突然减少

为什么是这个答案

当身体缺钠或缺水时，肾脏保留更多的钠，同时也保留锂，因此血锂水平升高。非甾体抗炎药、噻嗪类利尿剂和 ACE 抑制剂也可升高血锂水平。

答案

D · 脱水或钠摄入突然减少
6.实验室检查值与电解质

答案: D · 膝反射、呼吸频率和尿量

为什么是这个答案

膝反射消失是镁中毒的早期预警征象，出现在呼吸减慢之前。镁由肾脏清除，因此尿量下降会增加风险。静脉注射葡萄糖酸钙可拮抗镁中毒。核对依据: Magnesium Toxicity · StatPearls (NCBI Bookshelf) (2026); Magnesium Toxicity · StatPearls (NCBI Bookshelf)

答案

D · 膝反射、呼吸频率和尿量
7.临床护理

答案: D · Potassium, because both drugs can raise it

为什么是这个答案

Spironolactone and ACE inhibitors both reduce potassium excretion, so the combination can cause dangerous hyperkalaemia. Potassium and renal function should be checked regularly.

答案

D · Potassium, because both drugs can raise it
8.临床护理

答案: B · Massaging the calf

为什么是这个答案

Unilateral calf swelling and tenderness suggests DVT. Massaging the leg is avoided in case it dislodges the clot; the patient needs medical review and investigation.

答案

B · Massaging the calf
9.内外科护理：心血管与呼吸

答案: A · A previous haemorrhagic stroke

为什么是这个答案

Absolute contraindications include any previous intracranial haemorrhage, recent ischaemic stroke, active internal bleeding, suspected aortic dissection and recent major trauma or surgery. Thrombolysis is used when primary PCI cannot be delivered in time.

答案

A · A previous haemorrhagic stroke
10.内外科护理：心血管与呼吸

答案: C · A flail chest from ribs broken in more than one place

为什么是这个答案

A flail segment occurs when adjacent ribs are fractured in two or more places, so the segment moves paradoxically. It is often associated with lung contusion and respiratory failure. Management includes oxygen, strong analgesia and sometimes ventilation or surgical fixation.

答案

C · A flail chest from ribs broken in more than one place
11.内外科护理：神经、内分泌与肾脏

答案: A · "A few drinks tonight will help me relax and sleep."

为什么是这个答案

After a head injury, alcohol and sedatives should be avoided because they can mask drowsiness and confusion. A responsible adult should stay with the patient, and worsening headache, repeated vomiting, confusion or drowsiness mean they must return.

答案

A · "A few drinks tonight will help me relax and sleep."
12.内外科护理：神经、内分泌与肾脏

答案: D · Respect the decision and support symptom-focused care

为什么是这个答案

A competent patient can refuse dialysis. The nurse makes sure the choice is informed, respects it and supports conservative kidney management, with symptom control, advance care planning and palliative care input.

答案

D · Respect the decision and support symptom-focused care
13.内外科护理：消化、围手术期与肿瘤

答案: A · 通常约 48 小时

为什么是这个答案

许多细胞毒性药物在给药后的一段时间内会经尿、粪、呕吐物和其他体液排出。当地规定通常要求处理体液时戴手套和穿隔离衣约 48 小时，某些药物需要更长时间。

答案

A · 通常约 48 小时
14.内外科护理：消化、围手术期与肿瘤

答案: B · Keep the head of the bed at or below 30° if possible; use slide sheets

为什么是这个答案

A high head position makes patients slide, causing shear on the sacrum. A lower head position when clinically possible, knee break or foot support, and slide sheets for moving reduce shear and friction.

答案

B · Keep the head of the bed at or below 30° if possible; use slide sheets

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