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 receiving chemotherapy has a temperature of 38.3 °C and a very low neutrophil count. What should the nurse do?

  1. AGive a cool shower and offer extra fluids, then wait and see what happens
  2. BDocument the reading and mention it at the next handover
  3. CRecheck the temperature in four hours before telling anyone
  4. DReport it at once, because cultures and antibiotics are needed quickly
2.优先排序与委派困难

Two days after starting haloperidol, a patient suddenly develops painful neck twisting and the eyes roll upwards. What should the nurse anticipate?

  1. APhysical restraint until the spasm passes
  2. BAn anticholinergic drug, such as benztropine or procyclidine, as prescribed
  3. CA higher dose of haloperidol to calm the patient and stop the movements quickly
  4. DNo action, because the spasm is a sign of improvement
3.感染控制与患者安全中等

对乳胶过敏的患者，下列哪项患者安全措施最恰当？

  1. A护理患者时完全不戴手套
  2. B只使用有粉乳胶手套
  3. C使用无乳胶设备并清楚记录过敏情况
  4. D使用乳胶手套，之后认真洗手
4.感染控制与患者安全困难

哪项措施最能预防硬膜外输注的给药途径错误？

  1. A硬膜外接口堵塞时改用空闲的静脉接口
  2. B给硬膜外管路做标识，并让其使用专用的输注泵
  3. C患者的所有输注都使用同一类型的泵和输液管
  4. D把所有管路用胶带粘在一起以保持整齐
5.实验室检查值与电解质中等

The heparin infusion rate was changed according to protocol. When is the aPTT usually rechecked?

  1. AAbout 3 days after the change
  2. BAbout 6 hours after the change
  3. CAbout 30 minutes after the change
  4. DOnly after the infusion is stopped
6.实验室检查值与电解质困难

A patient on lithium has had vomiting and diarrhea for 3 days and has been taking ibuprofen. They now have a coarse tremor and confusion. The lithium level is 2.2 mEq/L. What is the best interpretation and action?

  1. AA normal level; continue lithium as prescribed
  2. BLithium toxicity; hold lithium and report urgently
  3. CIbuprofen side effects only; give it with food
  4. DA low level; ask for the lithium dose to be raised
7.临床护理中等

Why are patients asked to fast before a general anaesthetic?

  1. ATo lower the blood glucose before surgery
  2. BTo make the surgery shorter
  3. CTo prevent postoperative constipation and abdominal bloating
  4. DTo reduce the risk of aspirating stomach contents
8.临床护理困难

A patient has a high fever with rigors, jaundice and right upper quadrant pain. Which condition is most likely?

  1. AAcute appendicitis
  2. BSimple biliary colic
  3. CAscending cholangitis
  4. DGastro-oesophageal reflux disease
9.内外科护理：心血管与呼吸中等

一名患者因 DVT 开始服用华法林。为什么最初几天还要同时使用肝素或低分子量肝素？

  1. A肝素可改善华法林的吸收
  2. B肝素可预防华法林引起的出血
  3. C华法林需要几天才能达到完全的效果
  4. D这两种药必须一直合用，终身不能停
10.内外科护理：心血管与呼吸困难

A patient receiving weeks of IV antibiotics through a PICC line in the left arm develops swelling and aching of that arm and neck veins that look fuller on the left. What should the nurse suspect?

  1. ALymphoedema from lying in bed
  2. BAn expected effect of the antibiotic
  3. CA local skin allergy to the dressing
  4. DA catheter-related deep vein thrombosis
11.内外科护理：神经、内分泌与肾脏中等

A patient taking warfarin is diagnosed with an intracerebral haemorrhage. What is the priority treatment?

  1. ADoubling the warfarin dose to stabilise the INR
  2. BIV thrombolysis within 4.5 hours
  3. CStarting aspirin to prevent further clots
  4. DUrgent reversal of the anticoagulant effect
12.内外科护理：神经、内分泌与肾脏困难

A man who takes tamsulosin for BPH is listed for cataract surgery. Which statement is correct?

  1. AThe eye surgeon must be told, as it can cause floppy iris during surgery
  2. BTamsulosin has no effects outside the urinary tract, so nothing changes
  3. CIt should be swapped for oxybutynin the night before to protect the eye
  4. DThe dose should be doubled before surgery to prevent urinary retention
13.内外科护理：消化、围手术期与肿瘤中等

After a spinal anaesthetic, which nursing check is particularly important?

  1. ABlood glucose every 15 minutes overnight
  2. BPupil reaction every five minutes for the next full day
  3. CPeak flow before and after each meal
  4. DReturn of leg sensation and movement, and passing urine
14.内外科护理：消化、围手术期与肿瘤困难

A patient with facial burns from a house fire was talking normally on arrival. Two hours later, the voice is hoarse and there is stridor. What should the nurse do?

  1. ACall for urgent anaesthetic help, as the airway is swelling
  2. BLay the patient flat to help them sleep
  3. CGive a warm drink to soothe the throat
  4. DEncourage the patient to rest the voice and reassess tomorrow

3溶液

1.优先排序与委派

答案: D · Report it at once, because cultures and antibiotics are needed quickly

为什么是这个答案

Neutropenic fever is a medical emergency. The patient may have few other signs of infection, so the nurse reports it immediately so that cultures can be taken and IV antibiotics started.

答案

D · Report it at once, because cultures and antibiotics are needed quickly
2.优先排序与委派

答案: B · An anticholinergic drug, such as benztropine or procyclidine, as prescribed

为什么是这个答案

Acute dystonia is an early extrapyramidal effect of antipsychotics. It responds quickly to an anticholinergic drug; it can be frightening, and laryngeal spasm can threaten the airway.

答案

B · An anticholinergic drug, such as benztropine or procyclidine, as prescribed
3.感染控制与患者安全

答案: C · 使用无乳胶设备并清楚记录过敏情况

为什么是这个答案

应记录过敏情况，并让患者佩戴过敏腕带。使用无乳胶的手套、导尿管和其他设备，也可以清除房间内的乳胶制品。有粉乳胶手套尤其危险，因为粉末会把蛋白质带入空气中。

答案

C · 使用无乳胶设备并清楚记录过敏情况
4.感染控制与患者安全

答案: B · 给硬膜外管路做标识，并让其使用专用的输注泵

为什么是这个答案

在连接端给管路贴标识、使用不同（非 Luer）的接头以及单独并有明确标记的泵，可大大减少给药途径连接错误。连接之前应从患者开始沿管路追溯至源头。

答案

B · 给硬膜外管路做标识，并让其使用专用的输注泵
5.实验室检查值与电解质

答案: B · About 6 hours after the change

为什么是这个答案

Most weight-based heparin protocols check the aPTT (or anti-Xa level) about 6 hours after starting or changing the rate, because it takes this long to reach a new steady state. Checking too early can lead to wrong adjustments.

答案

B · About 6 hours after the change
6.实验室检查值与电解质

答案: B · Lithium toxicity; hold lithium and report urgently

为什么是这个答案

A level of 2.2 mEq/L with coarse tremor and confusion is lithium toxicity. Fluid loss and NSAIDs both reduce lithium excretion by the kidneys. The dose is held, the provider is informed at once, and fluids and close monitoring are expected; severe cases may need dialysis.

答案

B · Lithium toxicity; hold lithium and report urgently
7.临床护理

答案: D · To reduce the risk of aspirating stomach contents

为什么是这个答案

Under general anaesthesia the airway reflexes are lost, so food or fluid in the stomach could be regurgitated and inhaled. Fasting reduces the risk of aspiration pneumonitis.

答案

D · To reduce the risk of aspirating stomach contents
8.临床护理

答案: C · Ascending cholangitis

为什么是这个答案

Fever, jaundice and right upper quadrant pain (Charcot's triad) suggest infection of an obstructed bile duct. It can rapidly cause sepsis and needs antibiotics and biliary drainage.

答案

C · Ascending cholangitis
9.内外科护理：心血管与呼吸

答案: C · 华法林需要几天才能达到完全的效果

为什么是这个答案

华法林减少依赖维生素 K 的凝血因子的合成，但已有的凝血因子需要数天才能清除，而且早期可能短暂增加凝血倾向。肝素或低分子量肝素至少重叠使用五天，并持续到 INR 在目标范围内（通常 ≥2）至少 24 小时。

答案

C · 华法林需要几天才能达到完全的效果
10.内外科护理：心血管与呼吸

答案: D · A catheter-related deep vein thrombosis

为什么是这个答案

Upper-limb DVT is a recognised complication of PICCs and other central lines. Arm swelling, pain and distended veins should be reported, and an ultrasound arranged. The line is not flushed forcefully, and treatment usually involves anticoagulation.

答案

D · A catheter-related deep vein thrombosis
11.内外科护理：神经、内分泌与肾脏

答案: D · Urgent reversal of the anticoagulant effect

为什么是这个答案

Anticoagulants make the haematoma expand. Warfarin is reversed urgently, typically with prothrombin complex concentrate and IV vitamin K. Thrombolysis and antiplatelets are contraindicated in a bleed.

答案

D · Urgent reversal of the anticoagulant effect
12.内外科护理：神经、内分泌与肾脏

答案: A · The eye surgeon must be told, as it can cause floppy iris during surgery

为什么是这个答案

Tamsulosin blocks alpha-1A receptors in the iris dilator muscle as well as in the prostate, which can cause intraoperative floppy iris syndrome during cataract surgery. The effect can persist after the drug is stopped, so the surgeon must know in advance to plan the operation. Whether to pause it is a decision for the team.

答案

A · The eye surgeon must be told, as it can cause floppy iris during surgery
13.内外科护理：消化、围手术期与肿瘤

答案: D · Return of leg sensation and movement, and passing urine

为什么是这个答案

The nurse monitors the level of the block, recovery of leg movement and sensation, BP and bladder function. Urinary retention is common, and early mobilisation is only safe once motor function returns.

答案

D · Return of leg sensation and movement, and passing urine
14.内外科护理：消化、围手术期与肿瘤

答案: A · Call for urgent anaesthetic help, as the airway is swelling

为什么是这个答案

Progressive hoarseness and stridor after a facial or inhalation burn mean the airway is narrowing. Early intubation by an experienced anaesthetist is needed before swelling makes it impossible. The patient is sat up and given oxygen.

答案

A · Call for urgent anaesthetic help, as the airway is swelling

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