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

Straight after birth, what is the first priority for a healthy-looking newborn?

  1. AGive the vitamin K injection before anything else is done
  2. BWeigh and measure the baby on the scale
  3. CDry and warm the baby while checking that it is breathing
  4. DGive the first bath to remove the blood and vernix
2.优先排序与委派困难

An older patient has bruises of different ages and seems frightened when a relative visits. What is the nurse’s priority?

  1. ATell the patient she must leave home and go to live somewhere else
  2. BEnsure the patient’s safety, document the findings and report as required
  3. CIgnore it, because older people bruise easily
  4. DAsk the relative directly in front of the patient whether they hit her
3.感染控制与患者安全中等

When should the transparent dressing over a peripheral IV site be changed?

  1. AOnly when the IV catheter is removed, whatever its state
  2. BWhen it is damp, loose or visibly soiled
  3. COnly when the patient asks for a new dressing
  4. DEvery hour, so the site can be cleaned again
4.感染控制与患者安全困难

一名水痘患儿入院。由哪位工作人员护理该患儿最合适？

  1. A从未患过水痘也未接种过疫苗的护士
  2. B有书面记录证明对水痘有免疫力的护士
  3. C怀孕且不确定自己是否有免疫力的护士
  4. D免疫状况不明的实习护生
5.实验室检查值与电解质中等

A patient scheduled for surgery this morning has a potassium of 3.0 mEq/L on pre-operative tests. What should the nurse do?

  1. AGive an oral potassium dose without a prescription
  2. BSend the patient to surgery without comment
  3. CReport it to the surgical team before surgery
  4. DRepeat the test after the surgery is finished
6.实验室检查值与电解质困难

A patient with heavy alcohol use and a poor diet has a hemoglobin of 10.1 g/dL (101 g/L), an MCV of 110 fL and a low red cell folate. Which explanation fits best?

  1. AIron deficiency from slow, chronic bleeding in the gut
  2. BFolate deficiency, made worse by a direct alcohol effect
  3. CAnemia caused by long-standing chronic kidney disease
  4. DThalassemia trait inherited from one of the parents
7.临床护理中等

给予 β 受体阻滞剂之前，最重要的是检查哪项观察指标？

  1. A心率和血压
  2. B仅血糖
  3. C仅体温
  4. D排便情况
8.临床护理困难

A patient with hyperkalaemia is given IV insulin with glucose. What is the purpose, and what must be monitored?

  1. ATo protect the heart muscle directly; the patient must be kept nil by mouth
  2. BTo treat hidden diabetes; HbA1c must be checked daily
  3. CTo remove potassium from the body; urine output must be stopped for a time
  4. DTo shift potassium into cells; blood glucose must be monitored for hypoglycaemia
9.内外科护理：心血管与呼吸中等

Which finding shows that long-standing hypertension has caused target organ damage?

  1. AClear lung fields on the chest X-ray
  2. BA normal fasting glucose
  3. CA heart rate of 72/min
  4. DLeft ventricular hypertrophy on the ECG
10.内外科护理：心血管与呼吸困难

Which method best confirms that an endotracheal tube is in the trachea?

  1. AMisting inside the tube
  2. BThe chest rising on one side only
  3. CThe patient's skin colour improving
  4. DA sustained waveform on capnography
11.内外科护理：神经、内分泌与肾脏中等

A patient with advanced CKD asks how to manage indigestion. Which option should they avoid?

  1. AEating smaller, more frequent meals
  2. BMagnesium-containing antacids
  3. CRaising the head of the bed at night
  4. DAvoiding large meals late in the evening
12.内外科护理：神经、内分泌与肾脏困难

A patient with SIADH is taught about a fluid restriction. Which statement shows a need for further teaching?

  1. A"I will report any headaches or confusion."
  2. B"I will count all drinks, including soup, in my daily total."
  3. C"If I feel thirsty, I can drink as much water as I like."
  4. D"I will weigh myself every morning."
13.内外科护理：消化、围手术期与肿瘤中等

Which burn should usually be discussed with a specialist burns service even if it is small?

  1. AA healed burn scar from many years ago
  2. BA tiny burn on the forearm with redness only
  3. CA small superficial sunburn on the back
  4. DA partial-thickness burn on the hand
14.内外科护理：消化、围手术期与肿瘤困难

On the ward after surgery, a patient has a red, blistered area of skin under where the diathermy plate was. What should the nurse do?

  1. AIgnore it because skin changes after surgery are normal and expected to fade
  2. BWash it with alcohol and leave it uncovered
  3. CTreat it as a possible burn, report it and complete an incident form
  4. DApply a hot water bottle to improve the circulation

3溶液

1.优先排序与委派

答案: C · Dry and warm the baby while checking that it is breathing

为什么是这个答案

Breathing and keeping warm come first. Drying stimulates breathing and reduces heat loss; skin-to-skin contact helps. Weighing and routine injections can wait.

答案

C · Dry and warm the baby while checking that it is breathing
2.优先排序与委派

答案: B · Ensure the patient’s safety, document the findings and report as required

为什么是这个答案

Unexplained bruises of different ages and fear of a carer can suggest abuse. The nurse makes sure the patient is safe, documents objectively and reports according to law and policy.

答案

B · Ensure the patient’s safety, document the findings and report as required
3.感染控制与患者安全

答案: B · When it is damp, loose or visibly soiled

为什么是这个答案

A dressing that is wet, loose or dirty no longer protects the insertion site and is changed using aseptic technique. Otherwise, it is changed according to policy.

答案

B · When it is damp, loose or visibly soiled
4.感染控制与患者安全

答案: B · 有书面记录证明对水痘有免疫力的护士

为什么是这个答案

应由免疫状况确凿（来自接种疫苗或既往感染）的工作人员护理水痘患者。无免疫力的工作人员，尤其是孕期工作人员，有感染风险，并可能把病毒传给其他患者。

答案

B · 有书面记录证明对水痘有免疫力的护士
5.实验室检查值与电解质

答案: C · Report it to the surgical team before surgery

为什么是这个答案

Hypokalemia increases the risk of arrhythmias during anesthesia and can prolong muscle weakness. Abnormal pre-operative results are reported to the surgeon and anesthetist, who decide whether to correct it or delay surgery.核对依据: Hypokalemia · StatPearls (NCBI Bookshelf) (2025)

答案

C · Report it to the surgical team before surgery
6.实验室检查值与电解质

答案: B · Folate deficiency, made worse by a direct alcohol effect

为什么是这个答案

Poor diet and alcohol reduce folate intake and absorption, causing macrocytic anemia, and alcohol itself also raises the MCV. Iron deficiency and thalassemia cause small cells. Folate is replaced after B12 deficiency is excluded, and thiamine is also commonly given.核对依据: Folate-deficiency anemia - Medical Encyclopedia · MedlinePlus (NIH) (2026)

答案

B · Folate deficiency, made worse by a direct alcohol effect
7.临床护理

答案: A · 心率和血压

为什么是这个答案

β 受体阻滞剂会降低心率和血压，因此出现心动过缓或低血压时，可能需要暂停给药并通知开药者。

答案

A · 心率和血压
8.临床护理

答案: D · To shift potassium into cells; blood glucose must be monitored for hypoglycaemia

为什么是这个答案

Insulin drives potassium into cells, temporarily lowering serum levels. Glucose is given to prevent hypoglycaemia, but glucose monitoring is still needed for several hours.

答案

D · To shift potassium into cells; blood glucose must be monitored for hypoglycaemia
9.内外科护理：心血管与呼吸

答案: D · Left ventricular hypertrophy on the ECG

为什么是这个答案

Target organ damage from hypertension includes left ventricular hypertrophy, retinopathy, chronic kidney disease with proteinuria, and stroke. Its presence changes treatment urgency and targets.

答案

D · Left ventricular hypertrophy on the ECG
10.内外科护理：心血管与呼吸

答案: D · A sustained waveform on capnography

为什么是这个答案

A sustained exhaled carbon dioxide waveform confirms tracheal placement. Misting and chest movement can be misleading, and skin colour changes late. A chest X-ray shows the depth of the tube but does not prove it is in the trachea.

答案

D · A sustained waveform on capnography
11.内外科护理：神经、内分泌与肾脏

答案: B · Magnesium-containing antacids

为什么是这个答案

Magnesium and aluminium are excreted by the kidneys and can accumulate in kidney failure. Patients with CKD should check with a pharmacist before using over-the-counter remedies, including laxatives and NSAIDs.

答案

B · Magnesium-containing antacids
12.内外科护理：神经、内分泌与肾脏

答案: C · "If I feel thirsty, I can drink as much water as I like."

为什么是这个答案

In SIADH, the body keeps too much water. Drinking freely when thirsty would lower the sodium further. All fluids count towards the restriction. Daily weights and reporting neurological symptoms are correct.

答案

C · "If I feel thirsty, I can drink as much water as I like."
13.内外科护理：消化、围手术期与肿瘤

答案: D · A partial-thickness burn on the hand

为什么是这个答案

Burns of the face, hands, feet, genitalia, perineum and major joints, as well as circumferential, chemical, electrical and inhalation injuries, usually need specialist advice because of their risks and functional impact.

答案

D · A partial-thickness burn on the hand
14.内外科护理：消化、围手术期与肿瘤

答案: C · Treat it as a possible burn, report it and complete an incident form

为什么是这个答案

A blister under the return electrode suggests a diathermy burn. The nurse assesses and dresses it, informs the team, and reports it as an incident so that the cause can be investigated.

答案

C · Treat it as a possible burn, report it and complete an incident form

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