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

On day 3 after hip surgery, a patient suddenly becomes short of breath with sharp chest pain and an SpO₂ of 88%. What should the nurse do first?

  1. AGive the next dose of oral analgesia and reassess the patient in an hour
  2. BRaise the head of the bed, give oxygen and call for urgent help
  3. CEncourage the patient to walk to improve the circulation
  4. DMassage the patient’s calves to ease any muscle cramp
2.优先排序与委派困难

After a head injury, a patient passes large amounts of very dilute urine, is thirsty and has a rising serum sodium. Which condition is most likely?

  1. ASIADH
  2. BDiabetes insipidus
  3. CAcute kidney injury with oliguria
  4. DDiabetic ketoacidosis
3.感染控制与患者安全中等

同一病区有两位姓名非常相似的患者。最佳的安全措施是什么？

  1. A只用名字称呼每位患者
  2. B标记姓名相似的情况，并每次都核对两项识别信息
  3. C把其中一位患者转到另一家医院
  4. D用房间号区分患者
4.感染控制与患者安全困难

During a disaster, the hospital needs to free beds quickly. Which patient is the best candidate for early discharge?

  1. AA patient with ongoing chest pain awaiting cardiac tests
  2. BA patient on a ventilator in the intensive care unit who is slowly improving
  3. CA patient on an IV heparin infusion that is still being adjusted
  4. DA patient admitted overnight for observation who is now stable with normal tests
5.实验室检查值与电解质中等

为什么慢性肾脏病患者常有贫血？

  1. A肾病时的高钾使红细胞破裂
  2. B受损的肾脏过滤并破坏红细胞
  3. C尿毒症毒素使骨髓生成白细胞而不是红细胞
  4. D肾脏产生的促红细胞生成素减少，而它驱动红细胞的生成
6.实验室检查值与电解质困难

A patient with suspected Cushing syndrome takes dexamethasone at night. The next morning, the cortisol is still high. What does this suggest?

  1. AThe patient has primary hypothyroidism instead
  2. BThe result is normal, as dexamethasone raises cortisol
  3. CThe adrenal glands are not able to produce enough cortisol
  4. DCortisol is being produced without normal feedback control
7.临床护理中等

一名老年患者在病房中跌倒风险很高。哪项护理措施最恰当？

  1. A摘掉患者的眼镜以防摔坏
  2. B把呼叫铃和个人物品放在伸手可及处，并复核引起嗜睡的药物
  3. C始终让患者卧床
  4. D对每位患者都自动使用床栏
8.临床护理困难

A patient with several days of vomiting and diarrhoea has low blood pressure, low urine output and a rising creatinine. Which description fits best?

  1. APre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume
  2. BPost-renal acute kidney injury from obstruction, treated with a catheter
  3. CIntrinsic kidney injury from glomerulonephritis, treated with high-dose steroids
  4. DChronic kidney disease, treated with long-term dialysis three times a week
9.内外科护理：心血管与呼吸中等

哪些特征最能描述动脉性下肢溃疡？

  1. A脚趾上疼痛、苍白、边缘整齐如凿的溃疡，足部脉搏减弱
  2. B内踝上方浅表、潮湿的溃疡，周围皮肤呈棕色
  3. C前脚掌下无痛性溃疡，周围有厚厚的胼胝
  4. D小腿胫前渗液的溃疡，伴下肢凹陷性水肿
10.内外科护理：心血管与呼吸困难

A nurse teaches a patient who has a new permanent pacemaker. Which statement shows a need for further teaching?

  1. A"I will carry my pacemaker identification card with me at all times."
  2. B"I will tell staff about the device before any MRI scan."
  3. C"I will keep my mobile phone in my shirt pocket over the device."
  4. D"I will keep my follow-up appointments for device checks."
11.内外科护理：神经、内分泌与肾脏中等

Which picture fits Brown-Séquard syndrome?

  1. ALoss of all feeling but normal movement on both sides
  2. BParalysis of both legs, with normal sensation everywhere in the body
  3. CWeakness on the same side and loss of pain on the opposite side
  4. DWeakness of both arms with normal strength in the legs
12.内外科护理：神经、内分泌与肾脏困难

The day after a lumbar puncture, a patient has a headache that is severe when standing and almost gone when lying flat. Temperature and neck movement are normal. What is the most likely cause?

  1. AA subarachnoid haemorrhage
  2. BA migraine triggered by stress
  3. CBacterial meningitis from the procedure
  4. DPost-dural puncture headache
13.内外科护理：消化、围手术期与肿瘤中等

Which statement correctly describes physical dependence on opioids?

  1. AWithdrawal occurs if the drug is stopped suddenly
  2. BThe patient is allergic to opioids
  3. CThe drug no longer has any side effects
  4. DThe patient always craves the drug and misuses it despite harm
14.内外科护理：消化、围手术期与肿瘤困难

A sacral wound has heavy exudate, and the surrounding skin is white, soft and wrinkled. What should the nurse do?

  1. AProtect the skin edges and use a more absorbent dressing
  2. BUse a dressing that adds even more moisture
  3. CApply a tight plastic film directly over the wound
  4. DLeave the same dressing in place for a week so the wound is not disturbed

3溶液

1.优先排序与委派

答案: B · Raise the head of the bed, give oxygen and call for urgent help

为什么是这个答案

Sudden breathlessness and chest pain after surgery suggest a pulmonary embolism. The nurse supports breathing with positioning and oxygen and escalates at once; walking or leg massage could make things worse.

答案

B · Raise the head of the bed, give oxygen and call for urgent help
2.优先排序与委派

答案: B · Diabetes insipidus

为什么是这个答案

Damage to the pituitary or hypothalamus can stop the release of antidiuretic hormone, causing diabetes insipidus. The patient loses water, so urine is dilute and sodium rises; SIADH causes the opposite.

答案

B · Diabetes insipidus
3.感染控制与患者安全

答案: B · 标记姓名相似的情况，并每次都核对两项识别信息

为什么是这个答案

姓名警示系统（如贴纸或标识）可提醒工作人员，严格核对两项识别信息能防止混淆。房间号和名字都不可靠。

答案

B · 标记姓名相似的情况，并每次都核对两项识别信息
4.感染控制与患者安全

答案: D · A patient admitted overnight for observation who is now stable with normal tests

为什么是这个答案

In a surge, stable patients who could be safely cared for at home are discharged first. Patients who are unstable or need close monitoring or titrated infusions must stay.

答案

D · A patient admitted overnight for observation who is now stable with normal tests
5.实验室检查值与电解质

答案: D · 肾脏产生的促红细胞生成素减少，而它驱动红细胞的生成

为什么是这个答案

患病的肾脏产生的促红细胞生成素减少，因此骨髓生成的红细胞减少。治疗可包括促红细胞生成药物和铁剂。

答案

D · 肾脏产生的促红细胞生成素减少，而它驱动红细胞的生成
6.实验室检查值与电解质

答案: D · Cortisol is being produced without normal feedback control

为什么是这个答案

Dexamethasone normally suppresses ACTH and lowers morning cortisol. Failure to suppress suggests autonomous cortisol excess (Cushing syndrome). Further tests then find the source, such as a pituitary or adrenal tumor.

答案

D · Cortisol is being produced without normal feedback control
7.临床护理

答案: B · 把呼叫铃和个人物品放在伸手可及处，并复核引起嗜睡的药物

为什么是这个答案

预防跌倒包括评估危险因素、复核镇静类药物、提供眼镜、合适的鞋和助行器、把必需品放在伸手可及处以及协助如厕。

答案

B · 把呼叫铃和个人物品放在伸手可及处，并复核引起嗜睡的药物
8.临床护理

答案: A · Pre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume

为什么是这个答案

Fluid loss reduces kidney perfusion, causing pre-renal AKI. Prompt fluid replacement can restore function before the kidney tissue itself is damaged.

答案

A · Pre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume
9.内外科护理：心血管与呼吸

答案: A · 脚趾上疼痛、苍白、边缘整齐如凿的溃疡，足部脉搏减弱

为什么是这个答案

动脉性溃疡由缺血引起：深、边界清楚、苍白或坏死且疼痛，位于脚趾、足跟或受压点，周围皮肤发凉、无毛，脉搏减弱。内踝附近浅表潮湿的溃疡是静脉性的，伴胼胝的无痛性足底溃疡通常是神经病变性（糖尿病）的。

答案

A · 脚趾上疼痛、苍白、边缘整齐如凿的溃疡，足部脉搏减弱
10.内外科护理：心血管与呼吸

答案: C · "I will keep my mobile phone in my shirt pocket over the device."

为什么是这个答案

Patients are advised to keep mobile phones at least about 15 cm from the device and to hold them to the opposite ear. They carry a device card, tell staff before MRI or surgery (diathermy) and attend follow-up checks. Normal household appliances are generally safe.

答案

C · "I will keep my mobile phone in my shirt pocket over the device."
11.内外科护理：神经、内分泌与肾脏

答案: C · Weakness on the same side and loss of pain on the opposite side

为什么是这个答案

Damage to one side of the spinal cord, often from a stab wound, causes motor loss and loss of proprioception on the same side, and loss of pain and temperature on the opposite side. The pain fibres cross soon after entering the cord.

答案

C · Weakness on the same side and loss of pain on the opposite side
12.内外科护理：神经、内分泌与肾脏

答案: D · Post-dural puncture headache

为什么是这个答案

A positional headache after a lumbar puncture, without fever or neck stiffness, fits a CSF leak. It is managed with rest, fluids, analgesia and caffeine, and an epidural blood patch if it persists. Fever or neck stiffness would suggest infection instead.

答案

D · Post-dural puncture headache
13.内外科护理：消化、围手术期与肿瘤

答案: A · Withdrawal occurs if the drug is stopped suddenly

为什么是这个答案

Physical dependence is a predictable adaptation to regular opioids, causing withdrawal if they stop suddenly, so doses are tapered. Addiction is a behavioural condition with craving, loss of control and continued use despite harm.

答案

A · Withdrawal occurs if the drug is stopped suddenly
14.内外科护理：消化、围手术期与肿瘤

答案: A · Protect the skin edges and use a more absorbent dressing

为什么是这个答案

Maceration shows that exudate is not being managed. A barrier film or cream protects the surrounding skin, and a more absorbent dressing or more frequent changes are used. The cause of high exudate is reviewed.

答案

A · Protect the skin edges and use a more absorbent dressing

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