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 action helps prevent a catheter-associated urinary tract infection?

  1. ARaising the drainage bag above the bladder when walking
  2. BDisconnecting the bag every shift to empty it
  3. CLeaving the catheter in place longer than needed
  4. DKeeping the drainage bag below the level of the bladder
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. AIgnore it, because older people bruise easily
  2. BTell the patient she must leave home and go to live somewhere else
  3. CEnsure the patient’s safety, document the findings and report as required
  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

A patient with difficulty swallowing is prescribed an extended-release tablet. What should the nurse do?

  1. AAsk the prescriber or pharmacist for another form and not crush the tablet
  2. BCut the tablet in half so it is easier to swallow
  3. CDissolve the tablet in a glass of hot water
  4. DCrush the tablet finely and mix it into a spoonful of applesauce or yogurt
4.感染控制与患者安全困难

A woman in late pregnancy is choking and cannot speak or cough. Which technique should the rescuer use?

  1. ABlind finger sweeps
  2. BChest thrusts
  3. CBack blows only
  4. DAbdominal thrusts
5.实验室检查值与电解质中等

A patient with chronic kidney disease has a potassium of 5.6 mEq/L. Which food should the nurse advise the patient to limit?

  1. AWhite rice
  2. BBananas
  3. CCabbage
  4. DApples
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. BAnemia caused by long-standing chronic kidney disease
  3. CThalassemia trait inherited from one of the parents
  4. DFolate deficiency, made worse by a direct alcohol effect
7.临床护理中等

Which instruction is correct for taking weekly alendronic acid (alendronate)?

  1. ATake it with plain water on an empty stomach and stay upright for 30 minutes
  2. BTake it with an antacid to protect the stomach
  3. CChew the tablet with breakfast and a cup of milky tea
  4. DTake it with a glass of milk at bedtime and then lie down straight away
8.临床护理困难

A patient has a blood pressure of 220/130 mmHg with headache, confusion and visual disturbance. Why is the blood pressure lowered in a controlled way rather than as fast as possible?

  1. ABlood pressure cannot be lowered with drugs
  2. BRapid lowering causes hyperglycaemia
  3. CRapid lowering always causes the hypertension to come back much worse
  4. DA sudden drop can reduce blood flow to the brain, heart and kidneys
9.内外科护理：心血管与呼吸中等

A patient with a long QT interval develops a polymorphic ventricular tachycardia that twists around the baseline but still has a pulse. Which drug is used first?

  1. AIntravenous adenosine
  2. BIntravenous potassium chloride as a bolus
  3. CIntravenous magnesium sulfate
  4. DOral digoxin
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. AA single simple rib fracture with no lung injury
  2. BNormal chest movement caused by pain on breathing
  3. CA large pleural effusion pressing on the chest wall
  4. DA flail chest from ribs broken in more than one place
11.内外科护理：神经、内分泌与肾脏中等

A patient is due a rapid-acting insulin dose before lunch, but the meal trays are delayed. What should the nurse do?

  1. AGive the insulin with a glass of water instead
  2. BOmit the dose entirely for the rest of the day
  3. CWait to give the insulin until the meal arrives
  4. DGive the insulin now and the meal when it comes
12.内外科护理：神经、内分泌与肾脏困难

A patient has fever, confusion, odd behaviour and a new seizure. Herpes simplex encephalitis is suspected. Which drug is usually started straight away?

  1. AIV insulin
  2. BIV aciclovir
  3. COral amoxicillin
  4. DOral prednisolone
13.内外科护理：消化、围手术期与肿瘤中等

How is the height of an epidural sensory block usually checked?

  1. ATapping the knee with a reflex hammer and recording the score
  2. BChecking the colour of the patient's urine
  3. CTesting sensation to cold with ice or a cold spray
  4. DMeasuring the patient's blood glucose level
14.内外科护理：消化、围手术期与肿瘤困难

An incontinent patient has diffuse, shiny, red and broken skin in the natal cleft and buttocks with irregular edges, not over a bony prominence. What is most likely?

  1. AA full-thickness burn
  2. BIncontinence-associated dermatitis
  3. CA category 4 pressure ulcer over the sacrum
  4. DAn arterial ulcer caused by poor circulation

3溶液

1.优先排序与委派

答案: D · Keeping the drainage bag below the level of the bladder

为什么是这个答案

Keeping the bag below the bladder prevents backflow, and the closed system is not broken. Catheters are removed as soon as they are no longer needed.

答案

D · Keeping the drainage bag below the level of the bladder
2.优先排序与委派

答案: C · 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

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

答案: A · Ask the prescriber or pharmacist for another form and not crush the tablet

为什么是这个答案

Crushing or splitting an extended-release product can release the whole dose at once and cause toxicity. The nurse asks for a suitable alternative, such as a liquid or immediate-release form.

答案

A · Ask the prescriber or pharmacist for another form and not crush the tablet
4.感染控制与患者安全

答案: B · Chest thrusts

为什么是这个答案

For people in late pregnancy or who are very obese, chest thrusts replace abdominal thrusts because the rescuer cannot get around the abdomen effectively. Blind finger sweeps can push the object deeper.

答案

B · Chest thrusts
5.实验室检查值与电解质

答案: B · Bananas

为什么是这个答案

Bananas, oranges, potatoes, tomatoes, dried fruit and beans are high in potassium. Apples, white rice and cabbage are lower-potassium choices that are commonly allowed on a potassium-restricted diet.核对依据: Potassium in diet · MedlinePlus (NIH) (2026); Chronic kidney disease · MedlinePlus (NIH) (2025)

答案

B · Bananas
6.实验室检查值与电解质

答案: D · 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

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

答案: A · Take it with plain water on an empty stomach and stay upright for 30 minutes

为什么是这个答案

Alendronic acid must be taken with plain water before food, and the patient must stay upright to reduce oesophageal irritation. Food, milk and antacids reduce absorption.

答案

A · Take it with plain water on an empty stomach and stay upright for 30 minutes
8.临床护理

答案: D · A sudden drop can reduce blood flow to the brain, heart and kidneys

为什么是这个答案

In a hypertensive emergency, autoregulation in vital organs is reset to higher pressures. Lowering BP too fast can cause ischaemia, so it is reduced gradually under close monitoring.

答案

D · A sudden drop can reduce blood flow to the brain, heart and kidneys
9.内外科护理：心血管与呼吸

答案: C · Intravenous magnesium sulfate

为什么是这个答案

Torsades de pointes is treated with IV magnesium, plus correction of low potassium and stopping drugs that prolong the QT interval. If the patient loses their pulse, defibrillation is needed. Potassium must never be given as an IV bolus.

答案

C · Intravenous magnesium sulfate
10.内外科护理：心血管与呼吸

答案: D · 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

D · 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: C · Wait to give the insulin until the meal arrives

为什么是这个答案

Rapid-acting insulin begins to work within about 15 minutes, so giving it without food risks hypoglycaemia. It is given just before or with the meal. Basal insulin is not affected by meal delays.

答案

C · Wait to give the insulin until the meal arrives
12.内外科护理：神经、内分泌与肾脏

答案: B · IV aciclovir

为什么是这个答案

Herpes simplex encephalitis is treatable but can cause severe brain damage. IV aciclovir is started as soon as it is suspected, without waiting for test results. Kidney function and hydration are monitored during treatment.

答案

B · IV aciclovir
13.内外科护理：消化、围手术期与肿瘤

答案: C · Testing sensation to cold with ice or a cold spray

为什么是这个答案

The level at which the patient no longer feels cold shows the upper extent of the sensory block. Motor block is assessed with a scale such as Bromage. A rising block or new weakness is reported.

答案

C · Testing sensation to cold with ice or a cold spray
14.内外科护理：消化、围手术期与肿瘤

答案: B · Incontinence-associated dermatitis

为什么是这个答案

Incontinence-associated dermatitis is inflammation from urine or faeces, with diffuse redness and superficial erosion. It is managed with gentle cleansing, barrier products and managing incontinence, and is different from a pressure ulcer.

答案

B · Incontinence-associated dermatitis

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