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 a pediatric unit, which child does the nurse assess first?

  1. AA child with a temperature of 38.2 °C after vaccination
  2. BA child in a new arm cast with pink, warm fingers and pain of 5/10
  3. CA child with croup who has a barking cough but no stridor at rest
  4. DA child with asthma who is now quiet with very little air movement
2.优先排序与委派困难

A patient with COPD on 2 L/min oxygen becomes drowsy and hard to wake. The SpO₂ is 93%. What is the priority?

  1. AGive the as-needed sedative so the patient rests comfortably
  2. BIncrease the oxygen to 6 L/min so that the saturation goes even higher than now
  3. CAssess breathing and escalate for a blood gas, as carbon dioxide may be rising
  4. DLet the patient sleep, because the saturation is above target
3.感染控制与患者安全中等

患者的身份腕带丢失，而有一种药物到了给药时间。护士应怎么做？

  1. A先用两项识别信息确认身份，并重新戴上新腕带
  2. B直接给药，因为护士昨天就认识这位患者
  3. C跳过该药，等到第二天
  4. D用房间号和床号确认身份
4.感染控制与患者安全困难

Which patient with a suspected infection meets at least two SIRS criteria?

  1. ATemperature 38.6 °C and heart rate 112/min
  2. BRespiratory rate 16/min and WBC 8,000/mm3
  3. CTemperature 37.2 °C and heart rate 80/min
  4. DTemperature 36.8 °C and respiratory rate 18/min
5.实验室检查值与电解质中等

A patient with schizophrenia is starting clozapine. Which laboratory value must be monitored regularly?

  1. AInternational normalized ratio
  2. BSerum amylase
  3. CAbsolute neutrophil count
  4. DSerum lithium level
6.实验室检查值与电解质困难

A frail older adult in a nursing home has been drinking very little during a heat wave. She is confused, and her sodium is 158 mEq/L. Which treatment would the nurse expect?

  1. AGradual replacement of free water over many hours
  2. BRapid infusion of 3% saline to raise the volume
  3. CStrict fluid restriction to below 800 mL a day
  4. DA loop diuretic to remove the extra sodium quickly
7.临床护理中等

慢性肾病患者的饮食通常需要限制什么？

  1. A钾和磷
  2. B完全不吃碳水化合物
  3. C只限水溶性维生素
  4. D维生素 C 和膳食纤维
8.临床护理困难

Soon after starting chemotherapy for a high-grade lymphoma, a patient has rising potassium, phosphate and uric acid with falling urine output. What is the most likely cause?

  1. AAdrenal insufficiency
  2. BRefeeding syndrome
  3. CTumour lysis syndrome
  4. DSyndrome of inappropriate ADH secretion
9.内外科护理：心血管与呼吸中等

一名近期卒中且吞咽困难的患者出现发热和右下肺湿啰音。最可能的原因是什么？

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

In the first trimester of pregnancy, why is propylthiouracil often preferred to carbimazole for hyperthyroidism?

  1. APropylthiouracil has no side effects at all
  2. BCarbimazole has a higher risk of birth defects early on
  3. CCarbimazole cannot cross into the mother's blood
  4. DPropylthiouracil works faster than any other drug
12.内外科护理：神经、内分泌与肾脏困难

An adult stares blankly for about a minute, smacks their lips and fumbles with their clothes. Afterwards they are confused for ten minutes and remember nothing. Which seizure type fits best?

  1. AMyoclonic seizure
  2. BFocal impaired awareness seizure
  3. CAtonic (drop) seizure with a fall
  4. DAbsence seizure
13.内外科护理：消化、围手术期与肿瘤中等

Why are antibody levels checked after a healthcare worker receives the hepatitis B vaccine?

  1. ATo confirm that the vaccine produced immunity
  2. BTo decide whether they need a liver biopsy
  3. CTo measure liver damage caused by the vaccine
  4. DTo check whether they caught hepatitis B from the vaccine
14.内外科护理：消化、围手术期与肿瘤困难

一名两个月前放置了冠状动脉支架、服用阿司匹林和氯吡格雷的患者出现黑便，现在情况稳定。对抗血小板药物，最恰当的处理是什么？

  1. A两种药物原样继续，并且不向团队提及出血
  2. B将两种药物的剂量加倍，因为出血意味着支架有更大的血栓风险
  3. C永久停用两种药物，因为任何出血都意味着它们不再安全
  4. D报告出血；由团队在心脏科的参与下决定，权衡出血与支架血栓

3溶液

1.优先排序与委派

答案: D · A child with asthma who is now quiet with very little air movement

为什么是这个答案

In asthma, very little air movement and a quiet child mean severe obstruction and possible respiratory failure. The other children are stable for now.

答案

D · A child with asthma who is now quiet with very little air movement
2.优先排序与委派

答案: C · Assess breathing and escalate for a blood gas, as carbon dioxide may be rising

为什么是这个答案

In COPD, drowsiness can be a sign of carbon dioxide retention (hypercapnia), even when the saturation is acceptable. The nurse assesses breathing, escalates and avoids extra oxygen or sedatives that could worsen it.

答案

C · Assess breathing and escalate for a blood gas, as carbon dioxide may be rising
3.感染控制与患者安全

答案: A · 先用两项识别信息确认身份，并重新戴上新腕带

为什么是这个答案

每次给药都需要确认身份。护士用两项识别信息确认患者身份后，更换腕带。熟悉程度和房间号都不是可接受的识别信息。

答案

A · 先用两项识别信息确认身份，并重新戴上新腕带
4.感染控制与患者安全

答案: A · Temperature 38.6 °C and heart rate 112/min

为什么是这个答案

SIRS criteria include a temperature above 38 °C or below 36 °C, heart rate above 90/min, respiratory rate above 20/min and a WBC above 12,000 or below 4,000/mm3. Only the first patient meets two.

答案

A · Temperature 38.6 °C and heart rate 112/min
5.实验室检查值与电解质

答案: C · Absolute neutrophil count

为什么是这个答案

Clozapine can cause severe neutropenia (agranulocytosis), so the ANC is checked before starting and regularly during treatment. A sore throat, fever or other sign of infection must be reported at once.

答案

C · Absolute neutrophil count
6.实验室检查值与电解质

答案: A · Gradual replacement of free water over many hours

为什么是这个答案

Older adults have a reduced sense of thirst and easily develop hypernatremia from water loss. Free water is replaced gradually, because lowering sodium too quickly can cause cerebral edema. Hypertonic saline and fluid restriction would make it worse.

答案

A · Gradual replacement of free water over many hours
7.临床护理

答案: A · 钾和磷

为什么是这个答案

受损的肾脏难以排出钾和磷，因此常需要饮食限制，同时限制盐，有时还要限制液体和蛋白质。

答案

A · 钾和磷
8.临床护理

答案: C · Tumour lysis syndrome

为什么是这个答案

Rapid tumour cell death releases potassium, phosphate and nucleic acids (forming uric acid), which can cause AKI and arrhythmias. Prevention includes IV hydration and drugs to lower uric acid.

答案

C · Tumour lysis syndrome
9.内外科护理：心血管与呼吸

答案: D · 吸入性肺炎

为什么是这个答案

卒中后的吞咽困难增加了误吸的风险。误吸物常进入右下叶，因为右主支气管更宽、更垂直。吞咽筛查、直立体位和口腔护理可降低风险。

答案

D · 吸入性肺炎
10.内外科护理：心血管与呼吸

答案: B · "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

B · "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: B · Carbimazole has a higher risk of birth defects early on

为什么是这个答案

Carbimazole is linked to congenital abnormalities when used in early pregnancy, so propylthiouracil is often used in the first trimester. Propylthiouracil can cause serious liver injury, so it is not preferred at other times.

答案

B · Carbimazole has a higher risk of birth defects early on
12.内外科护理：神经、内分泌与肾脏

答案: B · Focal impaired awareness seizure

为什么是这个答案

Focal impaired awareness seizures often come from the temporal lobe. They last about a minute or two, with automatisms such as lip smacking and fumbling, and are followed by confusion. Absence seizures are shorter and have no postictal phase.

答案

B · Focal impaired awareness seizure
13.内外科护理：消化、围手术期与肿瘤

答案: A · To confirm that the vaccine produced immunity

为什么是这个答案

Some people do not develop protective anti-HBs antibodies after vaccination. Testing identifies non-responders, who may need further doses and advice after exposures.

答案

A · To confirm that the vaccine produced immunity
14.内外科护理：消化、围手术期与肿瘤

答案: D · 报告出血；由团队在心脏科的参与下决定，权衡出血与支架血栓

为什么是这个答案

冠状动脉支架置入后早期，停用双联抗血小板治疗有很高的支架血栓和心肌梗死风险，而继续使用则增加出血。决定由医疗团队作出，最好有心脏科和消化科参与；常继续阿司匹林，第二种药物则根据出血严重程度和内镜所见短暂暂停或继续使用。

答案

D · 报告出血；由团队在心脏科的参与下决定，权衡出血与支架血栓

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