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

An older patient becomes confused over a few hours, with attention that comes and goes. What does this suggest?

  1. AA personality change that is permanent and expected
  2. BLong-standing dementia that is expected
  3. CDelirium, which needs the cause found quickly
  4. DNormal aging that needs no action
2.优先排序与委派困难

A patient with raised intracranial pressure is being nursed on the ward. Which position is best?

  1. AFlat on the back with the head turned well over to one side
  2. BSitting forward with the chin on the chest
  3. CHead down with the legs raised above the heart
  4. DHead of the bed at about 30 degrees with the neck straight
3.感染控制与患者安全中等

When should a nurse call the rapid response team?

  1. AOnly when the provider has written an order for a rapid response call in the chart
  2. BOnly when the patient’s family makes a complaint
  3. CWhen a patient shows an acute decline, such as new confusion or a sharp change in vital signs
  4. DOnly after a patient has had a cardiac or respiratory arrest on the ward
4.感染控制与患者安全困难

The fire alarm sounds, but the nurse does not know where the fire is. What should the nurse do?

  1. ALeave the unit and the building to find out where the fire is
  2. BOpen all doors so patients can be seen easily
  3. CEvacuate all patients down the stairs at once, starting with those in bed
  4. DClose the doors to patient rooms, stay on the unit and wait for instructions
5.实验室检查值与电解质中等

A patient has macrocytic anemia with numbness and tingling of the feet and poor balance. Which deficiency is most likely?

  1. AIron (low ferritin)
  2. BVitamin B12
  3. CFolate (folic acid)
  4. DVitamin C (ascorbic acid)
6.实验室检查值与电解质困难

A patient has sudden episodes of severe headache, sweating, palpitations and very high blood pressure. Which test is most useful to look for the cause?

  1. APlasma free metanephrines
  2. BFasting lipid profile
  3. CSerum TSH and free T4
  4. DSerum calcium only
7.临床护理中等

Why is lactulose given to a patient with hepatic encephalopathy?

  1. ATo lower the blood glucose
  2. BTo increase the liver's production of albumin
  3. CTo reduce the absorption of ammonia from the gut
  4. DTo stop bleeding from varices
8.临床护理困难

A nurse teaches a patient with hypertension about their medicines. Which statement shows a need for further teaching?

  1. A"I'll keep taking my tablets even if I feel well."
  2. B"I'll get up slowly from sitting."
  3. C"I'll stop my tablets once my readings are normal."
  4. D"I'll have my blood pressure checked regularly."
9.内外科护理：心血管与呼吸中等

A patient on theophylline develops nausea, vomiting, a fast heart rate and restlessness. What should the nurse suspect?

  1. ATheophylline toxicity
  2. BA theophylline allergy causing a rash
  3. CAn expected sign that the drug is working
  4. DHypoglycaemia caused by the drug
10.内外科护理：心血管与呼吸困难

A patient with a confirmed type A aortic dissection is hypertensive and tachycardic while awaiting surgery. Which drug class is usually given first to lower the heart rate and blood pressure?

  1. AAn intravenous beta-blocker
  2. BAn intravenous fluid bolus
  3. COral aspirin
  4. DAn intravenous thrombolytic
11.内外科护理：神经、内分泌与肾脏中等

A patient who has had type 1 diabetes for 30 years says they no longer feel the warning signs of a hypo. What is this called?

  1. AInsulin resistance
  2. BThe dawn phenomenon
  3. CDiabetic ketoacidosis
  4. DHypoglycaemia unawareness
12.内外科护理：神经、内分泌与肾脏困难

A large pituitary tumour presses on the optic chiasm. Which visual field defect is most typical?

  1. AComplete blindness in one eye only
  2. BLoss of central vision in both eyes
  3. CLoss of the inner half of the field in both eyes
  4. DLoss of the outer half of the field in both eyes
13.内外科护理：消化、围手术期与肿瘤中等

造口袋底盘的开口应剪多大？

  1. A比造口四周大约 2–3 mm
  2. B比造口四周大约 2 cm
  3. C略小于造口以便紧密密封
  4. D任何大小，只要盖住造口即可
14.内外科护理：消化、围手术期与肿瘤困难

A patient who takes NSAIDs suddenly develops severe epigastric pain, a rigid abdomen and shoulder-tip pain. Which finding would most support the likely diagnosis?

  1. ATall, peaked T waves on a 12-lead ECG
  2. BA raised serum lipase three times the upper limit
  3. CFluid levels in the bladder on an ultrasound scan
  4. DFree air under the diaphragm on an erect chest X-ray

3溶液

1.优先排序与委派

答案: C · Delirium, which needs the cause found quickly

为什么是这个答案

Delirium starts suddenly, over hours or days, and attention fluctuates. It often has a treatable cause such as infection, hypoxia or medication, so it is a priority to assess.

答案

C · Delirium, which needs the cause found quickly
2.优先排序与委派

答案: D · Head of the bed at about 30 degrees with the neck straight

为什么是这个答案

Raising the head to about 30 degrees and keeping the neck in line helps venous drainage and lowers intracranial pressure. Head-down positions and neck bending or turning can raise it.

答案

D · Head of the bed at about 30 degrees with the neck straight
3.感染控制与患者安全

答案: C · When a patient shows an acute decline, such as new confusion or a sharp change in vital signs

为什么是这个答案

Rapid response teams bring critical care skills to a patient who is getting worse, with the aim of preventing cardiac arrest or ICU transfer. Any nurse who is worried about an acute change can call them.

答案

C · When a patient shows an acute decline, such as new confusion or a sharp change in vital signs
4.感染控制与患者安全

答案: D · Close the doors to patient rooms, stay on the unit and wait for instructions

为什么是这个答案

Closing doors limits the spread of smoke and fire. Staff follow the fire plan, keep corridors clear and prepare for evacuation, but do not evacuate until directed or the fire is in their area.

答案

D · Close the doors to patient rooms, stay on the unit and wait for instructions
5.实验室检查值与电解质

答案: B · Vitamin B12

为什么是这个答案

B12 and folate deficiencies both cause macrocytic anemia, but B12 deficiency also damages the spinal cord and peripheral nerves, causing numbness, tingling and poor balance. Neurological damage can become permanent if treatment is delayed.核对依据: Vitamin B12 deficiency anemia - Medical Encyclopedia · MedlinePlus (NIH) (2026); Vitamin B12 level - Medical Encyclopedia · MedlinePlus (NIH) (2026)

答案

B · Vitamin B12
6.实验室检查值与电解质

答案: A · Plasma free metanephrines

为什么是这个答案

These episodes suggest pheochromocytoma, a tumor of the adrenal medulla that releases catecholamines. Plasma free metanephrines (or 24-hour urine metanephrines) are the main screening tests. Hyperthyroidism can cause similar symptoms but usually without these bursts of severe hypertension.核对依据: Pheochromocytoma · MedlinePlus (NIH) (2024)

答案

A · Plasma free metanephrines
7.临床护理

答案: C · To reduce the absorption of ammonia from the gut

为什么是这个答案

Lactulose acidifies the colon and speeds transit, reducing ammonia absorption. The dose is usually adjusted to give two to three soft stools a day.

答案

C · To reduce the absorption of ammonia from the gut
8.临床护理

答案: C · "I'll stop my tablets once my readings are normal."

为什么是这个答案

Hypertension usually needs long-term treatment; stopping because readings are normal often makes blood pressure rise again. Patients should discuss any changes with their prescriber.

答案

C · "I'll stop my tablets once my readings are normal."
9.内外科护理：心血管与呼吸

答案: A · Theophylline toxicity

为什么是这个答案

Theophylline has a narrow therapeutic window. Toxicity causes nausea, vomiting, tachycardia, arrhythmias, agitation and seizures. Levels are monitored, and many drugs and smoking status change its clearance. The nurse should hold the dose and report.

答案

A · Theophylline toxicity
10.内外科护理：心血管与呼吸

答案: A · An intravenous beta-blocker

为什么是这个答案

In acute dissection, IV beta-blockers are usually given first to reduce heart rate and the rate of rise of pressure, limiting extension of the tear. Vasodilators may follow once the heart rate is controlled. Antiplatelets, anticoagulants and thrombolytics are avoided. Type A dissection needs urgent surgery.

答案

A · An intravenous beta-blocker
11.内外科护理：神经、内分泌与肾脏

答案: D · Hypoglycaemia unawareness

为什么是这个答案

Long duration of diabetes and frequent hypos reduce the adrenaline response, so warning symptoms are lost. This greatly increases the risk of severe hypos. Strict avoidance of hypos for some weeks can partly restore awareness, and glucose sensors with alarms help.

答案

D · Hypoglycaemia unawareness
12.内外科护理：神经、内分泌与肾脏

答案: D · Loss of the outer half of the field in both eyes

为什么是这个答案

The chiasm carries crossing fibres from the nasal retinas, which see the temporal (outer) fields. Compression causes a bitemporal hemianopia. Patients may bump into objects at their sides.

答案

D · Loss of the outer half of the field in both eyes
13.内外科护理：消化、围手术期与肿瘤

答案: A · 比造口四周大约 2–3 mm

为什么是这个答案

开口应剪得紧贴造口周围，留出约 2–3 mm（约 1/8 英寸）的小间隙。太大会使皮肤暴露于排出物；太小可能割伤造口。造口在最初几周内会缩小，所以要重复测量。

答案

A · 比造口四周大约 2–3 mm
14.内外科护理：消化、围手术期与肿瘤

答案: D · Free air under the diaphragm on an erect chest X-ray

为什么是这个答案

A perforated peptic ulcer releases air into the peritoneal cavity, seen under the diaphragm on an erect chest X-ray or on CT. Shoulder-tip pain is referred from diaphragmatic irritation. The patient is kept nil by mouth, resuscitated and referred urgently to surgeons.

答案

D · Free air under the diaphragm on an erect chest X-ray

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