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。

新题目返回课程

在打印窗口中选择“另存为 PDF”，即可在设备上保存一份副本。

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 newborn finding needs prompt reporting?

  1. AMild jaundice that first appears on the third day
  2. BMilia (small white spots) on the nose
  3. CBluish hands and feet in the first hours
  4. DJaundice that appears within the first 24 hours
2.优先排序与委派困难

A patient is going home on a new oral anticoagulant. There is only a short time for teaching. Which topic is most important?

  1. AWhich television programs help with relaxation
  2. BSigns of bleeding and when to seek help
  3. CHow to cook low-fat meals
  4. DHow to choose comfortable walking shoes
3.感染控制与患者安全中等

关于使用身体约束，下列哪项说法正确？

  1. A每班结束时检查一次约束即可
  2. B长期有效的“必要时”约束医嘱是良好的做法
  3. C只要病房护理人手不足就可以使用约束
  4. D首先采用替代措施，并需要有时限的医嘱
4.感染控制与患者安全困难

A nursing student describes how they remove PPE (gown, gloves and a mask worn for splash protection) at the doorway before leaving a contact precautions room. Which statement shows a need for further teaching?

  1. A“I clean my hands as soon as all the PPE is off.”
  2. B“I remove my gloves without touching the outside with my bare hand.”
  3. C“I take off my mask first, and then I take off my gloves.”
  4. D“I roll the gown inward as I take it off.”
5.实验室检查值与电解质中等

哪种心电图改变与低钙血症有关？

  1. AT 波高尖
  2. BQT 间期缩短
  3. CQT 间期延长
  4. D明显的 delta 波
6.实验室检查值与电解质困难

一名患者的钾几个月来一直是 3.4–3.6 mEq/L，今天的一次结果是 5.4 mEq/L。患者感觉良好，心电图正常。最好的下一步是什么？

  1. A停用患者所有的常规药物
  2. B忽略该结果，因为患者感觉良好
  3. C不做进一步检查，立即开始使用钾结合剂
  4. D检查样本是如何采集的，评估患者并重复检测
7.临床护理中等

A patient with DKA has an arterial blood gas showing a low pH and a low bicarbonate. Which disturbance is this?

  1. ARespiratory acidosis
  2. BRespiratory alkalosis
  3. CMetabolic acidosis
  4. DMetabolic alkalosis
8.临床护理困难

After a head injury, a patient has clear fluid leaking from the nose. What does this most likely suggest?

  1. AA base-of-skull fracture with a cerebrospinal fluid leak
  2. BAcute sinusitis
  3. CA normal and harmless response to head trauma
  4. DAllergic rhinitis triggered by the hospital environment
9.内外科护理：心血管与呼吸中等

A patient with chest pain has a first troponin result within the normal range one hour after the pain started. Why is a repeat test arranged?

  1. AThe repeat test is only needed for patients over 80
  2. BTroponin may take a few hours to rise after muscle damage
  3. CThe first sample is always contaminated
  4. DTroponin falls during an MI, so a lower value confirms it
10.内外科护理：心血管与呼吸困难

A nurse looked after a patient for a shift before smear-positive pulmonary TB was diagnosed, without wearing a respirator. What should happen?

  1. AStay off work for six months in case symptoms develop
  2. BTake no action, as healthcare workers are immune to TB
  3. CStart a full six-month course of TB drugs at once without any tests
  4. DReport it so occupational health can arrange follow-up screening
11.内外科护理：神经、内分泌与肾脏中等

A patient has just started haemodialysis. What usually happens to their protein needs?

  1. AProtein must be replaced only by IV infusion
  2. BThey stay exactly the same as they were before dialysis
  3. CThey increase, because dialysis removes amino acids
  4. DThey fall to almost zero to rest the kidneys
12.内外科护理：神经、内分泌与肾脏困难

一名 CKD 患者血红蛋白 92 g/L，开始使用促红细胞生成刺激剂（ESA）。护士应监测什么？

  1. A肝酶，因为 ESA 对肝脏有毒性
  2. B血糖，因为 ESA 常引起低血糖
  3. C血压和血红蛋白，因为超过目标会增加血栓风险
  4. D听力，因为 ESA 可损伤内耳
13.内外科护理：消化、围手术期与肿瘤中等

Which advice has good evidence for reducing cancer-related fatigue?

  1. AComplete bed rest for the whole course of treatment
  2. BAvoiding all daily activities
  3. CDrinking several strong coffees every evening
  4. DRegular light to moderate activity, such as walking
14.内外科护理：消化、围手术期与肿瘤困难

Which history should most alert the nurse to a possible latex allergy before surgery?

  1. AHay fever every spring since childhood
  2. BItching with bananas, avocado and kiwi, and many operations
  3. CA rash after taking amoxicillin as a child, with a family history of asthma
  4. DFeeling sick after eating shellfish once

3溶液

1.优先排序与委派

答案: D · Jaundice that appears within the first 24 hours

为什么是这个答案

Jaundice in the first 24 hours is not physiological and may point to hemolysis or infection. Mild jaundice after the first day, milia and acrocyanosis are common, expected findings.

答案

D · Jaundice that appears within the first 24 hours
2.优先排序与委派

答案: B · Signs of bleeding and when to seek help

为什么是这个答案

The main risk of anticoagulants is bleeding, so the patient must know the signs, such as black stools or blood in the urine, and when to seek help. Other topics can follow later.

答案

B · Signs of bleeding and when to seek help
3.感染控制与患者安全

答案: D · 首先采用替代措施，并需要有时限的医嘱

为什么是这个答案

只有在其他措施无效且患者或他人面临风险时才使用约束。需要有时限并定期复核的医嘱，不允许开“必要时”医嘱，并且要经常监测患者。

答案

D · 首先采用替代措施，并需要有时限的医嘱
4.感染控制与患者安全

答案: C · “I take off my mask first, and then I take off my gloves.”

为什么是这个答案

Gloves are the most contaminated item and are removed first, so dirty gloves do not touch the face or mask. Gown and gloves are taken off at the doorway before leaving the room, and hand hygiene follows. The other steps are correct.

答案

C · “I take off my mask first, and then I take off my gloves.”
5.实验室检查值与电解质

答案: C · QT 间期延长

为什么是这个答案

低钙使 QT 间期延长，可导致危险的心律失常。高钙使 QT 间期缩短，T 波高尖则是高钾血症的典型表现。

答案

C · QT 间期延长
6.实验室检查值与电解质

答案: D · 检查样本是如何采集的，评估患者并重复检测

为什么是这个答案

突然孤立的升高可能是真实的变化，例如由新药或肾损伤引起，也可能是样本问题，如溶血或处理前延迟。护士应评估患者，通知医疗人员并安排重复检测。核对依据: Hyperkalemia · StatPearls (NCBI Bookshelf) (2025)

答案

D · 检查样本是如何采集的，评估患者并重复检测
7.临床护理

答案: C · Metabolic acidosis

为什么是这个答案

In DKA, ketoacids consume bicarbonate, causing a metabolic acidosis. The patient breathes deeply and fast (Kussmaul breathing) to lower PaCO2 as compensation.

答案

C · Metabolic acidosis
8.临床护理

答案: A · A base-of-skull fracture with a cerebrospinal fluid leak

为什么是这个答案

Clear fluid from the nose or ear after head injury suggests a CSF leak from a skull base fracture, with a risk of meningitis. Nasal tubes and nose-blowing should be avoided and the patient reviewed urgently.

答案

A · A base-of-skull fracture with a cerebrospinal fluid leak
9.内外科护理：心血管与呼吸

答案: B · Troponin may take a few hours to rise after muscle damage

为什么是这个答案

Troponin starts to rise within hours of myocardial injury, so a very early result can be normal. Protocols use serial measurements at set intervals, with the ECG and clinical picture, to diagnose or exclude MI. A rising pattern supports acute injury.

答案

B · Troponin may take a few hours to rise after muscle damage
10.内外科护理：心血管与呼吸

答案: D · Report it so occupational health can arrange follow-up screening

为什么是这个答案

Contact tracing includes staff exposed without respiratory protection. Occupational health assesses the risk, checks for symptoms and arranges testing (for example IGRA) at suitable intervals. Treatment is offered for latent infection if found. Exposed people do not usually need to stop work unless they become unwell.

答案

D · Report it so occupational health can arrange follow-up screening
11.内外科护理：神经、内分泌与肾脏

答案: C · They increase, because dialysis removes amino acids

为什么是这个答案

Before dialysis, a moderate protein intake may be advised. Dialysis removes amino acids and protein, so needs rise, and malnutrition is a common risk. A renal dietitian sets individual targets.

答案

C · They increase, because dialysis removes amino acids
12.内外科护理：神经、内分泌与肾脏

答案: C · 血压和血红蛋白，因为超过目标会增加血栓风险

为什么是这个答案

ESA 可引起高血压，当血红蛋白被提升得过高时，还会增加血栓形成和卒中的风险。血红蛋白应控制在适中的范围（通常约 100–120 g/L）。应检查铁储备，因为缺铁会限制疗效。

答案

C · 血压和血红蛋白，因为超过目标会增加血栓风险
13.内外科护理：消化、围手术期与肿瘤

答案: D · Regular light to moderate activity, such as walking

为什么是这个答案

Exercise, matched to ability, reduces cancer-related fatigue. Pacing, prioritising activities, sleep routines and treating causes such as anaemia or depression also help.

答案

D · Regular light to moderate activity, such as walking
14.内外科护理：消化、围手术期与肿瘤

答案: B · Itching with bananas, avocado and kiwi, and many operations

为什么是这个答案

Latex–fruit syndrome links latex allergy with foods such as banana, avocado, kiwi and chestnut. Repeated exposure, for example through many operations or catheters, also increases risk.

答案

B · Itching with bananas, avocado and kiwi, and many operations

本内容为独立练习材料。ExamProblems 与该考试的主办机构没有隶属关系，也未获其认可，考试名称仅用于描述内容。 NCLEX®, NCLEX-RN® and NCLEX-PN® 是 the National Council of State Boards of Nursing, Inc. (NCSBN) 的商标，该机构与 ExamProblems 无关，不为其背书，也不保证其准确性。

ExamProblems · examproblems.com/courses/nclex-style-prioritization-and-delegation