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 patient with diabetes should the nurse see first?

  1. AHbA1c result of 8.2%, asking about diet
  2. BGlucose 48 mg/dL (2.7 mmol/L), sweating and confused
  3. CNeeds foot care teaching before discharge tomorrow
  4. DGlucose 210 mg/dL (11.7 mmol/L) after a large lunch, feels well
2.优先排序与委派困难

哪位患者的发现最紧急？

  1. A一名膝关节手术后的患者，注射部位有一小块瘀斑
  2. B一名服用华法林、INR 为 2.5 的患者，该服平常的晚间剂量
  3. C一名血小板计数结果尚未回报的患者
  4. D一名使用肝素输注的患者，新出现意识模糊和严重头痛
3.感染控制与患者安全中等

一名使用利尿剂的患者跌倒风险高，夜间常起床。下列哪项措施最有帮助？

  1. A定时协助如厕，并将呼叫器和助行器放在患者够得到的地方
  2. B告诉患者午饭后什么都不要喝
  3. C睡前给利尿剂，让药物在夜间起效
  4. D夜间保持房间完全黑暗以帮助患者入睡
4.感染控制与患者安全困难

A patient punches a nurse during care. The nurse is not seriously hurt. What should the nurse do?

  1. AGet medical assessment and report the assault according to policy
  2. BRefuse to care for any patient for the rest of the week until the patient is moved
  3. CPunch the patient back in self-defense
  4. DSay nothing, because violence is part of the job
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. AVitamin B12
  2. BVitamin C (ascorbic acid)
  3. CIron (low ferritin)
  4. DFolate (folic acid)
6.实验室检查值与电解质困难

Four drug levels are reported. Which patient should the nurse assess first?

  1. APhenytoin 15 mcg/mL with no symptoms
  2. BValproate 75 mcg/mL with no symptoms
  3. CLithium 1.8 mEq/L with a new coarse tremor
  4. DDigoxin 1.0 ng/mL with a pulse of 72/min
7.临床护理中等

How should a nurse communicate with a patient who has impaired hearing?

  1. AFace the patient, speak clearly and reduce background noise
  2. BSpeak very quickly to save time
  3. CShout loudly from the end of the bed so they can hear
  4. DTalk to the patient's relative instead of to the patient directly
8.临床护理困难

Why is a large pleural effusion drained slowly rather than all at once?

  1. ARapid drainage can cause re-expansion pulmonary oedema
  2. BSlow drainage stops the patient needing oxygen
  3. CFluid drained quickly turns into blood
  4. DQuick drainage causes the effusion to spread to the other lung
9.内外科护理：心血管与呼吸中等

为什么鼓励重度 COPD 患者少量多餐？

  1. A胃饱胀会限制膈肌活动，而且进食本身就很累
  2. B频繁进餐可直接预防胸部感染
  3. C大餐会使气道永久性变窄
  4. D少量进餐可减少使用吸入器的次数
10.内外科护理：心血管与呼吸困难

Ten days after cardiac surgery, a patient has a fever, a red sternal wound with discharge and a clicking feeling in the chest when coughing. What should the nurse suspect?

  1. ANormal wound healing with some expected discharge
  2. BPericarditis from the operation
  3. CSternal wound infection with an unstable sternum
  4. DCostochondritis caused by forceful coughing
11.内外科护理：神经、内分泌与肾脏中等

Which signs suggest rejection of a kidney transplant?

  1. AMore urine, a falling creatinine and weight loss
  2. BLess urine, a rising creatinine and a tender graft
  3. CA cough, wheeze and a runny nose with sneezing
  4. DA rash on the face after sun exposure
12.内外科护理：神经、内分泌与肾脏困难

A haemodialysis patient missed their last two sessions. They are breathless, with crackles, and the potassium is 6.9 mmol/L. What is the priority?

  1. AOral potassium supplements and rest
  2. BA routine dialysis session at the next planned slot
  3. CLarge IV fluid boluses to improve the circulation
  4. DUrgent dialysis, with cardiac monitoring meanwhile
13.内外科护理：消化、围手术期与肿瘤中等

为什么在计算补液复苏的烧伤面积时，不计入浅表烧伤（仅发红，如晒伤）？

  1. A它们总是太小，无法在图表上准确测量
  2. B它们引起的液体丢失比其他任何深度都多
  3. C皮肤屏障完整，丢失的液体很少
  4. D它们总是在一天内完全愈合
14.内外科护理：消化、围手术期与肿瘤困难

A patient taking oral capecitabine reports red, painful, peeling palms and soles. What should the nurse do?

  1. AReport it; this is hand-foot syndrome and treatment may need changing
  2. BAdvise hot soaks for the hands and feet
  3. CReassure that it is a sign of an unrelated allergy to washing powder
  4. DTell the patient to take a double dose next time

3溶液

1.优先排序与委派

答案: B · Glucose 48 mg/dL (2.7 mmol/L), sweating and confused

为什么是这个答案

Severe hypoglycemia with confusion can quickly lead to seizures and loss of consciousness. The other patients have problems that matter but are not immediately dangerous.

答案

B · Glucose 48 mg/dL (2.7 mmol/L), sweating and confused
2.优先排序与委派

答案: D · 一名使用肝素输注的患者，新出现意识模糊和严重头痛

为什么是这个答案

接受抗凝治疗的患者新出现意识模糊和剧烈头痛，可能意味着颅内出血。INR 2.5 在 2 至 3 的常用治疗范围内，注射部位的小瘀斑很常见。

答案

D · 一名使用肝素输注的患者，新出现意识模糊和严重头痛
3.感染控制与患者安全

答案: A · 定时协助如厕，并将呼叫器和助行器放在患者够得到的地方

为什么是这个答案

定时协助如厕，并把呼叫器和助行器放在可及之处，可减少无人协助的行走。利尿剂在早晨而不是睡前给药也有帮助。夜灯比完全黑暗更安全，无故限制液体可能导致脱水。

答案

A · 定时协助如厕，并将呼叫器和助行器放在患者够得到的地方
4.感染控制与患者安全

答案: A · Get medical assessment and report the assault according to policy

为什么是这个答案

Workplace violence should always be reported. Reporting allows care for the injured staff member, review of risks and changes to the patient’s care plan to protect staff and other patients.

答案

A · Get medical assessment and report the assault according to policy
5.实验室检查值与电解质

答案: A · 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

A · Vitamin B12
6.实验室检查值与电解质

答案: C · Lithium 1.8 mEq/L with a new coarse tremor

为什么是这个答案

A lithium level of 1.8 mEq/L with a coarse tremor suggests toxicity, which can progress to confusion and seizures. The digoxin, phenytoin and valproate levels are within commonly cited ranges and the patients are stable.

答案

C · Lithium 1.8 mEq/L with a new coarse tremor
7.临床护理

答案: A · Face the patient, speak clearly and reduce background noise

为什么是这个答案

Facing the patient in good light, speaking clearly at a normal pace, checking hearing aids and reducing noise improves communication. Written information can also help.

答案

A · Face the patient, speak clearly and reduce background noise
8.临床护理

答案: A · Rapid drainage can cause re-expansion pulmonary oedema

为什么是这个答案

Draining a large volume quickly can cause re-expansion pulmonary oedema, with cough, chest tightness and hypoxia. Drainage is controlled, and the patient is watched closely.

答案

A · Rapid drainage can cause re-expansion pulmonary oedema
9.内外科护理：心血管与呼吸

答案: A · 胃饱胀会限制膈肌活动，而且进食本身就很累

为什么是这个答案

许多重度 COPD 患者体重下降，因为呼吸消耗大量能量，而大餐会引起腹胀和呼吸困难。少量、营养密度高的餐食有助于维持体重和肌力。

答案

A · 胃饱胀会限制膈肌活动，而且进食本身就很累
10.内外科护理：心血管与呼吸

答案: C · Sternal wound infection with an unstable sternum

为什么是这个答案

Deep sternal wound infection and sternal dehiscence are serious complications, more common with diabetes, obesity and COPD. Signs include fever, wound discharge, redness and an unstable or clicking sternum. Urgent surgical review, wound swabs, blood cultures and antibiotics are needed.

答案

C · Sternal wound infection with an unstable sternum
11.内外科护理：神经、内分泌与肾脏

答案: B · Less urine, a rising creatinine and a tender graft

为什么是这个答案

Acute rejection may cause falling urine output, rising creatinine, weight gain, fever, and pain or tenderness over the graft. Many episodes are found on blood tests before symptoms appear, so regular monitoring is essential.

答案

B · Less urine, a rising creatinine and a tender graft
12.内外科护理：神经、内分泌与肾脏

答案: D · Urgent dialysis, with cardiac monitoring meanwhile

为什么是这个答案

Missing dialysis causes fluid overload and hyperkalaemia, both of which can be fatal. The patient needs cardiac monitoring, emergency treatment of the potassium and urgent dialysis to remove fluid and potassium.

答案

D · Urgent dialysis, with cardiac monitoring meanwhile
13.内外科护理：消化、围手术期与肿瘤

答案: C · 皮肤屏障完整，丢失的液体很少

为什么是这个答案

浅表（表皮）烧伤引起疼痛和发红，但不会像部分层和全层烧伤那样引起毛细血管渗漏和液体丢失。把它们计入会高估烧伤面积，导致补液过多。

答案

C · 皮肤屏障完整，丢失的液体很少
14.内外科护理：消化、围手术期与肿瘤

答案: A · Report it; this is hand-foot syndrome and treatment may need changing

为什么是这个答案

Palmar-plantar erythrodysaesthesia (hand-foot syndrome) is common with capecitabine and fluorouracil. It is graded and may need a treatment break or dose reduction; emollients and avoiding heat and friction help.

答案

A · Report it; this is hand-foot syndrome and treatment may need changing

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