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 clozapine reports a sore throat and fever. What is the priority action?

  1. AOffer throat lozenges and continue the usual dose
  2. BIncrease the dose because the symptoms suggest a relapse
  3. CAdvise the patient to gargle with warm salt water and rest in bed
  4. DHold the dose and report so the white cell count can be checked
2.优先排序与委派困难

护士应首先看哪名儿童？

  1. A一名哮喘的青少年，呼气峰流速为个人最佳值的 90%
  2. B一名腿上打石膏、要求喝水的学龄儿童
  3. C一名体温 38.4 °C、正在玩玩具的幼儿
  4. D一名 RSV 感染的婴儿，有鼻翼扇动、胸壁凹陷和 89% 的 SpO₂
3.感染控制与患者安全中等

Why is blood glucose control important around the time of surgery?

  1. AGlucose levels only affect patients who have type 1 diabetes
  2. BLow glucose is needed around surgery so that the wound edges close more quickly
  3. CHigh glucose makes anesthetic drugs work for much longer and delays waking up
  4. DHigh glucose impairs white cell function and raises the risk of surgical site infection
4.感染控制与患者安全困难

Minutes after the first IV dose of an antibiotic starts, the patient develops wheezing, hives and low blood pressure. What should the nurse do first?

  1. AGive an oral antihistamine
  2. BRecord the new allergy in the chart
  3. CStop the infusion
  4. DSlow the infusion rate
5.实验室检查值与电解质中等

A patient has taken hydrochlorothiazide for several years. Which laboratory change is a recognized effect of this drug?

  1. AA rise in serum potassium
  2. BA fall in blood glucose
  3. CA rise in serum uric acid
  4. DA fall in serum calcium
6.实验室检查值与电解质困难

手术后，一名接受大量低渗静脉液体的患者出现头痛、恶心和意识模糊。哪项结果最能解释这一点？

  1. A钙 9.4 mg/dL（2.35 mmol/L）
  2. B血糖 110 mg/dL（6.1 mmol/L）
  3. C钠 126 mEq/L
  4. D钾 4.2 mEq/L
7.临床护理中等

What is the recommended first aid for a thermal burn?

  1. AApply ice directly to the burn until the pain stops completely
  2. BBurst any blisters to release the fluid
  3. CSpread butter or oil over the burn
  4. DCool it under cool running water for about 20 minutes
8.临床护理困难

交接班开始时，病房护士应首先评估哪位患者？

  1. A新出现意识混乱、呼吸频率 28 次/分的患者
  2. B要求使用缓泻剂的患者
  3. C生命体征平稳、等待出院的患者
  4. D慢性背痛评分 4/10 的患者
9.内外科护理：心血管与呼吸中等

Why is active tuberculosis treated with several drugs for at least six months?

  1. ABecause the bacteria are resistant to all drugs at first
  2. BTo kill slow-growing bacteria and prevent drug resistance
  3. CBecause each drug works on a different organ only
  4. DTo reduce the number of side effects compared with one drug
10.内外科护理：心血管与呼吸困难

一名心力衰竭患者静息时呼吸困难，四肢末梢发凉，收缩压 80 mmHg，尿量减少。这提示什么？

  1. A稳定、代偿良好的慢性心力衰竭
  2. B心源性休克伴组织灌注不良
  3. C口服补液即可纠正的轻度脱水
  4. D焦虑引起的血管迷走神经反应
11.内外科护理：神经、内分泌与肾脏中等

A routine blood test shows a potassium of 6.4 mmol/L. The lab reports that the sample was haemolysed. The patient feels well. What should the nurse do?

  1. AIgnore it, because haemolysis always gives a normal result
  2. BStart dialysis as soon as possible
  3. CInform the doctor and arrange an urgent repeat sample
  4. DGive oral potassium supplements straight away
12.内外科护理：神经、内分泌与肾脏困难

A patient with Parkinson's disease becomes agitated and confused at night. Which newly prescribed drug should the nurse question?

  1. AMelatonin
  2. BLactulose
  3. CParacetamol (acetaminophen)
  4. DHaloperidol
13.内外科护理：消化、围手术期与肿瘤中等

Which nerve is at risk if the arm is poorly padded at the elbow during surgery?

  1. AFacial nerve
  2. BFemoral nerve
  3. CUlnar nerve
  4. DSciatic nerve
14.内外科护理：消化、围手术期与肿瘤困难

On the day after a Hartmann's procedure, the end colostomy is dark purple to black. What should the nurse do?

  1. ARub the stoma to improve its colour
  2. BRecord it as normal postoperative bruising and recheck it next week
  3. CReport it urgently, as the stoma may be necrotic
  4. DCut a smaller hole in the pouch

3溶液

1.优先排序与委派

答案: D · Hold the dose and report so the white cell count can be checked

为什么是这个答案

Clozapine can cause agranulocytosis. A sore throat or fever may be the first sign of infection, so the nurse reports it and the neutrophil count is checked before more doses are given.

答案

D · Hold the dose and report so the white cell count can be checked
2.优先排序与委派

答案: D · 一名 RSV 感染的婴儿，有鼻翼扇动、胸壁凹陷和 89% 的 SpO₂

为什么是这个答案

鼻翼扇动、凹陷和低 SpO₂ 显示呼吸窘迫，婴儿可能迅速恶化。正在玩耍的发热儿童、口渴的儿童以及峰流速接近正常的青少年都是稳定的。

答案

D · 一名 RSV 感染的婴儿，有鼻翼扇动、胸壁凹陷和 89% 的 SpO₂
3.感染控制与患者安全

答案: D · High glucose impairs white cell function and raises the risk of surgical site infection

为什么是这个答案

Hyperglycemia weakens neutrophil function and slows healing, so it increases the risk of surgical site infection. Keeping glucose in the target range is part of infection prevention for surgical patients.

答案

D · High glucose impairs white cell function and raises the risk of surgical site infection
4.感染控制与患者安全

答案: C · Stop the infusion

为什么是这个答案

These are signs of anaphylaxis. The nurse stops the infusion at once, calls for help and supports the airway, and intramuscular epinephrine (adrenaline) is the first-line treatment. Documentation comes later.

答案

C · Stop the infusion
5.实验室检查值与电解质

答案: C · A rise in serum uric acid

为什么是这个答案

Thiazides reduce uric acid excretion and can trigger gout. They also tend to lower potassium, sodium and magnesium, raise calcium (by reducing its excretion) and raise blood glucose and lipids.

答案

C · A rise in serum uric acid
6.实验室检查值与电解质

答案: C · 钠 126 mEq/L

为什么是这个答案

手术应激使抗利尿激素升高，低渗液体增加自由水，因此钠下降。低钠血症引起头痛、恶心和意识模糊。其他数值是正常的。

答案

C · 钠 126 mEq/L
7.临床护理

答案: D · Cool it under cool running water for about 20 minutes

为什么是这个答案

Cooling with running water for around 20 minutes limits tissue damage and pain. Ice can cause further injury, and the patient should be kept warm while the burn is cooled.

答案

D · Cool it under cool running water for about 20 minutes
8.临床护理

答案: A · 新出现意识混乱、呼吸频率 28 次/分的患者

为什么是这个答案

新出现的意识混乱伴呼吸急促提示急性病情恶化，例如脓毒症或缺氧。病情稳定的慢性问题患者可以稍后处理。

答案

A · 新出现意识混乱、呼吸频率 28 次/分的患者
9.内外科护理：心血管与呼吸

答案: B · To kill slow-growing bacteria and prevent drug resistance

为什么是这个答案

Mycobacterium tuberculosis grows slowly and has resistant mutants in any large population. A combination (for example rifampicin, isoniazid, pyrazinamide and ethambutol at first) kills susceptible and resistant bacteria and prevents resistance. Stopping early risks relapse and multidrug-resistant TB.

答案

B · To kill slow-growing bacteria and prevent drug resistance
10.内外科护理：心血管与呼吸

答案: B · 心源性休克伴组织灌注不良

为什么是这个答案

心源性休克是泵衰竭，伴低血压和低灌注（皮肤发凉、少尿、意识混乱、乳酸升高），常伴肺淤血。需要紧急的重症监护评估。除非经仔细评估指导，否则大剂量快速补液可使淤血加重。

答案

B · 心源性休克伴组织灌注不良
11.内外科护理：神经、内分泌与肾脏

答案: C · Inform the doctor and arrange an urgent repeat sample

为什么是这个答案

Haemolysis releases potassium from red cells and can falsely raise the result. A repeat sample is taken urgently, and an ECG may be done. If the ECG shows hyperkalaemic changes, treatment should not wait.

答案

C · Inform the doctor and arrange an urgent repeat sample
12.内外科护理：神经、内分泌与肾脏

答案: D · Haloperidol

为什么是这个答案

Haloperidol is a dopamine antagonist and can severely worsen parkinsonian symptoms. Metoclopramide is avoided for the same reason. Causes of delirium should be looked for, and specialist advice is needed if a drug is required.

答案

D · Haloperidol
13.内外科护理：消化、围手术期与肿瘤

答案: C · Ulnar nerve

为什么是这个答案

The ulnar nerve runs superficially at the elbow and is a common site of positioning injury. Careful padding and avoiding pressure on the elbow help prevent numbness and weakness of the hand.

答案

C · Ulnar nerve
14.内外科护理：消化、围手术期与肿瘤

答案: C · Report it urgently, as the stoma may be necrotic

为什么是这个答案

A dark or black stoma suggests poor blood supply and necrosis, which can extend below the skin. The surgical team must assess it urgently, as further surgery may be needed.

答案

C · Report it urgently, as the stoma may be necrotic

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