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 swimmer is found unresponsive after diving into shallow water. Which method should the nurse use to open the airway?

  1. ATurning the head to the side to drain water
  2. BJaw thrust, keeping the head and neck in line
  3. CHead-tilt, chin-lift with full neck extension
  4. DRaising the chin while bending the neck forward
2.优先排序与委派困难

During an infusion of a thrombolytic drug for stroke, the patient develops a severe headache and starts vomiting. What should the nurse do first?

  1. AStop the infusion and inform the provider at once
  2. BContinue the infusion, because headache is expected
  3. CGive a dose of aspirin for the headache
  4. DSlow the infusion and give an antiemetic as prescribed
3.感染控制与患者安全中等

Sputum specimens are ordered to look for acid-fast bacilli (TB). How are they usually collected?

  1. AThree deep-cough specimens collected 8 to 24 hours apart, at least one early in the morning
  2. BThree specimens collected after an antiseptic mouthwash
  3. COne specimen of sputum collected straight after the evening meal, when coughing is easiest
  4. DOne saliva sample collected at any convenient time of day
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. BClose the doors to patient rooms, stay on the unit and wait for instructions
  3. COpen all doors so patients can be seen easily
  4. DEvacuate all patients down the stairs at once, starting with those in bed
5.实验室检查值与电解质中等

A patient has weight loss, tremor and heat intolerance. Which thyroid test pattern fits Graves disease?

  1. AHigh TSH with a normal free T4
  2. BLow TSH with a high free T4
  3. CHigh TSH with a low free T4
  4. DNormal TSH with a low free T4
6.实验室检查值与电解质困难

The nurse teaches a patient who is collecting a 24-hour urine sample at home. Which statement shows a need for further teaching?

  1. A"I'll empty my bladder at the end time and add that urine"
  2. B"If I forget to save one void, I'll just carry on to the end"
  3. C"I'll ask whether any foods or drugs should be avoided first"
  4. D"I'll keep the container cool as the laboratory told me to"
7.临床护理中等

Which of these is one of the "4 Hs", the reversible causes of cardiac arrest?

  1. AHypoxia
  2. BHypertension
  3. CHyperventilation
  4. DHyperthyroidism
8.临床护理困难

一名使用阿片类 PCA 泵的患者呼吸频率为 7 次/分，且难以唤醒。首先应该做什么？

  1. A记录生命体征，在下一次每四小时一次的巡视时复查
  2. B鼓励患者更频繁地按 PCA 按钮以求舒适
  3. C增加 PCA 单次剂量，因为患者可能在疼痛
  4. D停用 PCA，唤醒患者，给氧，并尽快给予纳洛酮
9.内外科护理：心血管与呼吸中等

Septic shock belongs to which category of shock?

  1. AObstructive shock
  2. BDistributive shock
  3. CHypovolaemic shock
  4. DCardiogenic shock
10.内外科护理：心血管与呼吸困难

一名二尖瓣机械瓣置换术后服用华法林的患者 INR 为 2.2。护士应考虑什么？

  1. AINR 高到危险程度，必须暂停用药
  2. BINR 在所有华法林适应证的范围内，所以无需处理
  3. C机械瓣的 INR 应在约 1.0
  4. DINR 可能低于该患者较高的目标值，应核查并上报
11.内外科护理：神经、内分泌与肾脏中等

Why may a person with long-standing diabetes have a heart attack without typical chest pain?

  1. AInsulin acts as a strong painkiller
  2. BHigh glucose protects the heart from pain
  3. CNerve damage can blunt the pain signals
  4. DPeople with diabetes do not have heart attacks
12.内外科护理：神经、内分泌与肾脏困难

The nurse has four patients with diabetes. Which one needs to be seen first?

  1. AA newly diagnosed patient asking about which foods to eat
  2. BA patient with a glucose of 14 mmol/L (252 mg/dL) who feels well and is eating
  3. CA patient waiting for a routine HbA1c test
  4. DA patient with a glucose of 2.8 mmol/L (50 mg/dL) who is sweaty and confused
13.内外科护理：消化、围手术期与肿瘤中等

手术后哪个时期最可能发生伤口裂开？

  1. A最初一小时内
  2. B术后约 5–10 天
  3. C仅在手术过程中
  4. D术后一年以上
14.内外科护理：消化、围手术期与肿瘤困难

一名化疗后接受非格司亭（G-CSF）的患者询问会有什么副作用。最常见的副作用是什么？

  1. A永久性听力丧失
  2. B骨痛，因为骨髓受到刺激
  3. C首次注射后数天内完全脱发
  4. D白细胞计数迅速下降

3溶液

1.优先排序与委派

答案: B · Jaw thrust, keeping the head and neck in line

为什么是这个答案

A diving injury may damage the cervical spine. A jaw thrust opens the airway with little neck movement; if it fails, the airway still takes priority.

答案

B · Jaw thrust, keeping the head and neck in line
2.优先排序与委派

答案: A · Stop the infusion and inform the provider at once

为什么是这个答案

A new severe headache, vomiting or neurological decline during thrombolysis can mean intracranial bleeding. The infusion is stopped, the provider informed and an urgent scan arranged.

答案

A · Stop the infusion and inform the provider at once
3.感染控制与患者安全

答案: A · Three deep-cough specimens collected 8 to 24 hours apart, at least one early in the morning

为什么是这个答案

Several deep-cough sputum samples improve the chance of finding acid-fast bacilli, and early-morning samples contain the most secretions. Saliva is not sputum, and antiseptic mouthwash can affect the result.

答案

A · Three deep-cough specimens collected 8 to 24 hours apart, at least one early in the morning
4.感染控制与患者安全

答案: B · 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

B · 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 · Low TSH with a high free T4

为什么是这个答案

In Graves disease, antibodies stimulate the thyroid to make too much hormone. The high free T4 suppresses TSH from the pituitary through negative feedback, so TSH is low. A high TSH with a low T4 fits primary hypothyroidism.核对依据: TSH test · MedlinePlus (NIH) (2026); Thyroxine (T4) Test · MedlinePlus (NIH) (2024); Graves disease · MedlinePlus (NIH) (2026)

答案

B · Low TSH with a high free T4
6.实验室检查值与电解质

答案: B · "If I forget to save one void, I'll just carry on to the end"

为什么是这个答案

A 24-hour collection is valid only if every void in the period is saved; if a void is lost, the nurse or clinic is told and the collection is usually restarted. Keeping the container cool as instructed, adding the final void at the end time and asking about restrictions are correct.核对依据: Urine 24-hour volume · MedlinePlus (NIH) (2025)

答案

B · "If I forget to save one void, I'll just carry on to the end"
7.临床护理

答案: A · Hypoxia

为什么是这个答案

The 4 Hs are hypoxia, hypovolaemia, hypo- or hyperkalaemia and other metabolic causes, and hypothermia. The 4 Ts are thrombosis, tension pneumothorax, tamponade and toxins.

答案

A · Hypoxia
8.临床护理

答案: D · 停用 PCA，唤醒患者，给氧，并尽快给予纳洛酮

为什么是这个答案

过度镇静和呼吸缓慢提示阿片类药物中毒。应停用阿片类药物，支持气道和呼吸，给氧，遵医嘱给予纳洛酮，并密切监测。

答案

D · 停用 PCA，唤醒患者，给氧，并尽快给予纳洛酮
9.内外科护理：心血管与呼吸

答案: B · Distributive shock

为什么是这个答案

In distributive shock (septic, anaphylactic, neurogenic), vessels dilate and leak, so blood is maldistributed and pressure falls. Obstructive shock includes PE, tamponade and tension pneumothorax; cardiogenic shock is pump failure; hypovolaemic shock is volume loss.

答案

B · Distributive shock
10.内外科护理：心血管与呼吸

答案: D · INR 可能低于该患者较高的目标值，应核查并上报

为什么是这个答案

机械心脏瓣膜，尤其是二尖瓣位置，通常需要更高的 INR 目标（例如 2.5–3.5，取决于瓣膜类型和危险因素）。INR 2.2 可能未达治疗水平，增加瓣膜血栓和卒中的风险。护士应核对记录的目标值并通知开处方者。机械瓣不使用 DOAC。

答案

D · INR 可能低于该患者较高的目标值，应核查并上报
11.内外科护理：神经、内分泌与肾脏

答案: C · Nerve damage can blunt the pain signals

为什么是这个答案

Autonomic neuropathy can make a myocardial infarction "silent" or atypical, with breathlessness, fatigue, nausea or sweating rather than chest pain. A low threshold for an ECG is needed.

答案

C · Nerve damage can blunt the pain signals
12.内外科护理：神经、内分泌与肾脏

答案: D · A patient with a glucose of 2.8 mmol/L (50 mg/dL) who is sweaty and confused

为什么是这个答案

Hypoglycaemia with confusion can rapidly lead to seizures and loss of consciousness, so it is treated at once. A moderately high glucose without symptoms, diet questions and routine tests can wait.

答案

D · A patient with a glucose of 2.8 mmol/L (50 mg/dL) who is sweaty and confused
13.内外科护理：消化、围手术期与肿瘤

答案: B · 术后约 5–10 天

为什么是这个答案

伤口裂开最常发生在第 5–10 天左右，此时伤口依赖缝线和早期胶原。危险因素包括肥胖、营养不良、糖尿病、感染、使用类固醇、吸烟、咳嗽和用力。

答案

B · 术后约 5–10 天
14.内外科护理：消化、围手术期与肿瘤

答案: B · 骨痛，因为骨髓受到刺激

为什么是这个答案

粒细胞集落刺激因子刺激骨髓生成中性粒细胞，常引起骨痛，尤其是背部、骨盆和长骨；通常按医嘱用简单镇痛药处理。罕见但严重的副作用是脾破裂，因此新出现的左上腹或肩尖痛必须立即报告。

答案

B · 骨痛，因为骨髓受到刺激

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