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 patient receives hemodialysis this morning. Which type of medication is often held before dialysis, as prescribed?

  1. AEye drops for glaucoma
  2. BAntihypertensive drugs
  3. CTopical skin creams
  4. DInhaled bronchodilators
2.优先排序与委派困难

A patient admitted with a stroke this morning asks for a glass of water. What should the nurse do first?

  1. AAsk the family to help the patient drink while sitting upright in a chair at the bedside
  2. BCheck that a swallow screen has been done before giving anything by mouth
  3. CGive the water through a straw so it goes down slowly
  4. DGive thickened fluids without checking the swallow
3.感染控制与患者安全中等

Before a defibrillator shock is delivered, what must the person operating it do?

  1. AHold the patient’s hand to keep them still
  2. BCall “all clear” and check that nobody is touching the patient or bed
  3. CKeep the oxygen mask on the patient’s face, held against the chest
  4. DAsk a colleague to hold the paddles in place
4.感染控制与患者安全困难

A nurse caring for a patient with influenza on droplet precautions will assist with an aerosol-generating procedure, such as bronchoscopy. What change in PPE is needed?

  1. ANo change, because influenza only needs droplet precautions
  2. BWear a fit-tested respirator (N95 or FFP3) and eye protection instead of a surgical mask
  3. CWear two surgical masks, one on top of the other, for the length of the procedure
  4. DWear gloves only, because the procedure is short
5.实验室检查值与电解质中等

A urine culture report states "mixed growth of three organisms, likely contamination." What is the nurse's best response?

  1. ARecord the result as a confirmed urinary tract infection
  2. BInform the provider and arrange a new, correctly collected sample
  3. CStart treatment for all three organisms with three antibiotics
  4. DDiscard the report, because a mixed growth is always normal
6.实验室检查值与电解质困难

在对生长迅速的淋巴瘤化疗后，哪种结果模式提示肿瘤溶解综合征？

  1. A仅有高钠和低血糖
  2. B高钾、高磷、高尿酸和低钙
  3. C低钾、低磷、低尿酸和高钙
  4. D电解质正常，血红蛋白高
7.临床护理中等

Which pattern is typical of relapsing–remitting multiple sclerosis?

  1. AA single stroke that leaves permanent weakness
  2. BAttacks of symptoms, such as visual loss or numbness, that improve between relapses
  3. CSudden severe headache with neck stiffness
  4. DConstant weakness that starts in the feet and spreads upwards after a viral illness
8.临床护理困难

Why is morphine more likely to cause toxicity in a patient with severe kidney impairment?

  1. AIts active metabolites build up because the kidneys excrete them
  2. BKidney disease makes the opioid receptors disappear
  3. CThe kidneys normally activate morphine, so more of it becomes active
  4. DKidney failure makes the stomach absorb more morphine
9.内外科护理：心血管与呼吸中等

A 34-year-old has hypertension that is hard to control and a low serum potassium without taking diuretics. Which cause should be considered?

  1. AHypothyroidism
  2. BEssential hypertension of ageing
  3. CIron-deficiency anaemia
  4. DPrimary hyperaldosteronism
10.内外科护理：心血管与呼吸困难

髋关节手术后，一名患者突然出现呼吸困难和焦虑，心率 124 次/分，未吸氧时 SpO₂ 86%，呼吸时有尖锐疼痛。听诊胸部清晰。护士首先应做什么？

  1. A带患者在病房里走动以改善呼吸
  2. B给镇静剂缓解焦虑，一小时后复查
  3. C给氧、协助坐起、呼叫紧急评估并留在床边
  4. D让患者平躺，双腿用枕头抬高
11.内外科护理：神经、内分泌与肾脏中等

A man starts finasteride for an enlarged prostate. Which statement is correct?

  1. AIt works within hours by relaxing the bladder muscle
  2. BIt lowers the blood pressure, so dizziness is very common
  3. CIt takes months to work; pregnant women must not handle broken tablets
  4. DIt is used only for a few days at a time
12.内外科护理：神经、内分泌与肾脏困难

A patient with lung cancer is confused, dehydrated and constipated, with a corrected calcium of 3.4 mmol/L (about 13.6 mg/dL). What is usually the first treatment?

  1. AOral calcium tablets
  2. BA fluid restriction
  3. CIV fluids to rehydrate the patient
  4. DIV calcium gluconate and vitamin D
13.内外科护理：消化、围手术期与肿瘤中等

What is anticipatory nausea in chemotherapy?

  1. ANausea caused by low blood glucose
  2. BNausea caused only by the smell of food
  3. CNausea that starts about a week after each cycle and lasts for days
  4. DNausea triggered by reminders of treatment before it is given
14.内外科护理：消化、围手术期与肿瘤困难

一名肺癌患者出现面部肿胀、颈静脉怒张，平卧时呼吸困难加重。可能是哪种急症？

  1. A上腔静脉阻塞
  2. B脊髓压迫
  3. C恶性肿瘤相关高钙血症
  4. D大面积肺栓塞

3溶液

1.优先排序与委派

答案: B · Antihypertensive drugs

为什么是这个答案

Removing fluid during dialysis can cause hypotension, so blood pressure drugs are often held before treatment as prescribed. Some drugs are also removed by dialysis and given afterwards.

答案

B · Antihypertensive drugs
2.优先排序与委派

答案: B · Check that a swallow screen has been done before giving anything by mouth

为什么是这个答案

After a stroke, the patient stays NPO (nothing by mouth) until a swallow screen shows it is safe. Giving fluids first risks aspiration, even with a straw or thickener.

答案

B · Check that a swallow screen has been done before giving anything by mouth
3.感染控制与患者安全

答案: B · Call “all clear” and check that nobody is touching the patient or bed

为什么是这个答案

Anyone touching the patient or bed could receive the shock. The operator announces “clear” and looks to confirm that nobody is in contact, and oxygen is moved away from the chest.

答案

B · Call “all clear” and check that nobody is touching the patient or bed
4.感染控制与患者安全

答案: B · Wear a fit-tested respirator (N95 or FFP3) and eye protection instead of a surgical mask

为什么是这个答案

Aerosol-generating procedures can spread influenza in small particles that a surgical mask does not filter well. Staff wear a fit-tested respirator (N95 in the US, FFP3 in the UK), eye protection, gown and gloves, and the number of people in the room is kept low.

答案

B · Wear a fit-tested respirator (N95 or FFP3) and eye protection instead of a surgical mask
5.实验室检查值与电解质

答案: B · Inform the provider and arrange a new, correctly collected sample

为什么是这个答案

Several organisms in one urine sample usually mean contamination from the skin or perineum during collection. The provider is informed, and a new clean-catch or catheter-port sample is usually needed before an infection can be confirmed.

答案

B · Inform the provider and arrange a new, correctly collected sample
6.实验室检查值与电解质

答案: B · 高钾、高磷、高尿酸和低钙

为什么是这个答案

当大量肿瘤细胞破裂时，钾、磷酸盐和核酸（转变为尿酸）涌入血液。磷酸盐与钙结合，因此钙下降。风险包括心律失常和急性肾损伤。核对依据: Tumor Lysis Syndrome (StatPearls) · StatPearls (NCBI Bookshelf) (2024)

答案

B · 高钾、高磷、高尿酸和低钙
7.临床护理

答案: B · Attacks of symptoms, such as visual loss or numbness, that improve between relapses

为什么是这个答案

MS causes demyelination in the brain and spinal cord. Many patients first have attacks such as optic neuritis or sensory symptoms, with partial or full recovery between relapses.

答案

B · Attacks of symptoms, such as visual loss or numbness, that improve between relapses
8.临床护理

答案: A · Its active metabolites build up because the kidneys excrete them

为什么是这个答案

Morphine metabolites, including morphine-6-glucuronide, are cleared by the kidneys and accumulate in renal impairment, causing sedation and respiratory depression. Alternative opioids or lower doses are often chosen.

答案

A · Its active metabolites build up because the kidneys excrete them
9.内外科护理：心血管与呼吸

答案: D · Primary hyperaldosteronism

为什么是这个答案

Excess aldosterone (for example from an adrenal adenoma, Conn's syndrome) causes sodium retention, hypertension and potassium loss. Young age, resistant hypertension and unexplained hypokalaemia suggest a secondary cause and need investigation.

答案

D · Primary hyperaldosteronism
10.内外科护理：心血管与呼吸

答案: C · 给氧、协助坐起、呼叫紧急评估并留在床边

为什么是这个答案

骨科手术后突发呼吸困难、心动过速、胸膜性疼痛和低氧血症提示肺栓塞。立即措施是支持性的：给氧至目标饱和度、血压允许时取直立位、紧急上报并持续监测，随后按医嘱进行检查和抗凝。镇静可能掩盖病情恶化并抑制呼吸。

答案

C · 给氧、协助坐起、呼叫紧急评估并留在床边
11.内外科护理：神经、内分泌与肾脏

答案: C · It takes months to work; pregnant women must not handle broken tablets

为什么是这个答案

Finasteride, a 5-alpha reductase inhibitor, reduces the conversion of testosterone to dihydrotestosterone and shrinks the prostate over several months. It can harm a male fetus, so pregnant women should avoid handling crushed or broken tablets.

答案

C · It takes months to work; pregnant women must not handle broken tablets
12.内外科护理：神经、内分泌与肾脏

答案: C · IV fluids to rehydrate the patient

为什么是这个答案

Hypercalcaemia causes polyuria and dehydration, which worsen the high calcium. IV fluids are the first step, followed by a bisphosphonate to reduce bone resorption. Calcium is rechecked regularly.

答案

C · IV fluids to rehydrate the patient
13.内外科护理：消化、围手术期与肿瘤

答案: D · Nausea triggered by reminders of treatment before it is given

为什么是这个答案

Anticipatory nausea is a conditioned response after previous poorly controlled nausea, triggered by sights or smells linked to treatment. Good antiemetic control from the first cycle helps prevent it; relaxation techniques and anxiolytics may help.

答案

D · Nausea triggered by reminders of treatment before it is given
14.内外科护理：消化、围手术期与肿瘤

答案: A · 上腔静脉阻塞

为什么是这个答案

肿瘤可压迫或侵犯上腔静脉，引起面部和手臂肿胀、胸壁静脉扩张、头痛和呼吸困难。应让患者坐起并紧急评估；治疗包括类固醇、支架置入以及放疗或化疗。

答案

A · 上腔静脉阻塞

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