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 parent calls to say their toddler has just swallowed drain cleaner. What should the nurse advise?

  1. AMake the child vomit straight away to bring up the chemical
  2. BDo not make the child vomit; call poison control or emergency services now
  3. CWait to see whether the child develops any symptoms first
  4. DGive a large glass of fizzy drink or milk to dilute the cleaner before calling anyone
2.优先排序与委派困难

A marathon runner is confused, with a temperature of 41 °C and hot skin. What is the priority?

  1. AWrapping the runner in a blanket to prevent shivering
  2. BAsking the runner to rest in the shade and drink slowly
  3. CGiving an antipyretic tablet and waiting for it to work
  4. DRapid cooling while supporting airway and circulation
3.感染控制与患者安全中等

Which drugs are used as antidotes for nerve agent poisoning?

  1. AAcetylcysteine and charcoal
  2. BAtropine and pralidoxime
  3. CVitamin K and protamine
  4. DNaloxone and flumazenil
4.感染控制与患者安全困难

A nurse discovers that an insulin infusion was programmed using the wrong drug concentration in the pump library. What should the nurse do first?

  1. ALeave it running and check the glucose at the next routine time
  2. BReprogram the pump and finish the shift before reporting
  3. CDouble the rate to correct for the error
  4. DStop the infusion and check the patient’s blood glucose
5.实验室检查值与电解质中等

For most hospitalized adults with diabetes who are critically ill, which glucose target range is commonly recommended?

  1. AAbout 140–180 mg/dL (7.8–10 mmol/L)
  2. BAbout 300–350 mg/dL (16.7–19.4 mmol/L)
  3. CAbout 60–80 mg/dL (3.3–4.4 mmol/L)
  4. DAbout 250–300 mg/dL (13.9–16.7 mmol/L)
6.实验室检查值与电解质困难

Four results arrive at the same time. Which patient should the nurse see first?

  1. AWhite cell count 12.0 × 10³/µL on the first day after surgery
  2. BHemoglobin 10.4 g/dL (104 g/L) in a patient with stable chronic kidney disease
  3. CINR 2.6 in a patient on warfarin for atrial fibrillation
  4. DGlucose 48 mg/dL (2.7 mmol/L) in a patient who had insulin an hour ago
7.临床护理中等

In suspected sepsis, what should ideally be collected before the first dose of antibiotics, as long as it does not delay treatment?

  1. AA stool sample for occult blood
  2. BA 24-hour urine collection
  3. CA fasting cholesterol level
  4. DBlood cultures
8.临床护理困难

内科病房一名患者已腹泻三天。最恰当的感染控制措施是什么？

  1. A等腹泻持续一周后再采取任何措施
  2. B立即隔离，采取接触防护，并送检粪便标本
  3. C把患者移到多人病房，以便空出单间
  4. D只用含酒精的手消毒剂，不戴手套以节省资源
9.内外科护理：心血管与呼吸中等

A patient with angle-closure glaucoma needs nebulised ipratropium. What precaution is sensible?

  1. AUse a mouthpiece or protect the eyes from the mist
  2. BGive it only with the patient lying completely flat
  3. CMix it with an eye drop before putting it in the nebuliser
  4. DRun it at the highest possible gas flow
10.内外科护理：心血管与呼吸困难

A patient with end-stage COPD has severe breathlessness at rest despite optimal treatment and wants comfort-focused care. Which measure is recognised to help?

  1. AEncouraging long walks to build fitness
  2. BStopping all medicines, including inhalers
  3. CA low-dose opioid with a hand-held fan and calm positioning
  4. DHigh-flow oxygen at 15 L/min whatever the oxygen saturation is
11.内外科护理：神经、内分泌与肾脏中等

A patient with a spinal cord injury can still feel a light touch around the anus. What does this show?

  1. AThe patient has an injury of the brain, not the cord
  2. BThe injury is incomplete, which suggests a better chance of recovery
  3. CThe injury is complete, and recovery is not possible
  4. DThe sensation is only a spinal reflex and has no real meaning for recovery
12.内外科护理：神经、内分泌与肾脏困难

A patient who had pituitary surgery has fatigue and feels cold. TSH is low, and free T4 is low. What is the most likely cause?

  1. AHyperthyroidism from Graves' disease
  2. BSecondary hypothyroidism
  3. CPrimary hypothyroidism from thyroid failure
  4. DOver-replacement with levothyroxine
13.内外科护理：消化、围手术期与肿瘤中等

A day after a spinal anaesthetic, a patient has a headache that is worse when sitting up and better when lying flat. What is the most likely cause?

  1. AMigraine caused by hospital lighting
  2. BRaised blood pressure from pain
  3. CA side effect of the antibiotic
  4. DPost-dural puncture headache
14.内外科护理：消化、围手术期与肿瘤困难

An older patient on regular opioids has small amounts of liquid stool leaking all day, but has not had a formed bowel movement for 6 days. What is the most likely cause?

  1. AFaecal impaction with overflow
  2. BA flare of ulcerative colitis
  3. CAcute infective gastroenteritis
  4. DNormal stool pattern on opioids

3溶液

1.优先排序与委派

答案: B · Do not make the child vomit; call poison control or emergency services now

为什么是这个答案

Inducing vomiting after a corrosive is swallowed causes more burns to the throat and risks aspiration. The parent should get expert advice and emergency help at once.

答案

B · Do not make the child vomit; call poison control or emergency services now
2.优先排序与委派

答案: D · Rapid cooling while supporting airway and circulation

为什么是这个答案

Heat stroke is an emergency in which body temperature rises and the brain is affected. Rapid cooling, for example with cold water or ice, is the priority; antipyretics do not work for heat stroke.

答案

D · Rapid cooling while supporting airway and circulation
3.感染控制与患者安全

答案: B · Atropine and pralidoxime

为什么是这个答案

Nerve agents inhibit acetylcholinesterase, causing excess acetylcholine. Atropine blocks muscarinic effects such as secretions and bradycardia, and pralidoxime helps to reactivate the enzyme.

答案

B · Atropine and pralidoxime
4.感染控制与患者安全

答案: D · Stop the infusion and check the patient’s blood glucose

为什么是这个答案

A concentration error means the dose delivered was wrong. The nurse stops the infusion, assesses the patient including blood glucose, treats as needed, notifies the prescriber and reports the event.

答案

D · Stop the infusion and check the patient’s blood glucose
5.实验室检查值与电解质

答案: A · About 140–180 mg/dL (7.8–10 mmol/L)

为什么是这个答案

For most critically ill patients, insulin is used to keep glucose around 140–180 mg/dL (7.8–10 mmol/L). Lower targets increase the risk of hypoglycemia, and persistently higher levels increase infection and other complications.

答案

A · About 140–180 mg/dL (7.8–10 mmol/L)
6.实验室检查值与电解质

答案: D · Glucose 48 mg/dL (2.7 mmol/L) in a patient who had insulin an hour ago

为什么是这个答案

Hypoglycemia after insulin can quickly cause seizures and loss of consciousness, so it is treated first. Mild anemia in CKD is expected, an INR of 2.6 is within the target range, and a slightly raised white count is common after surgery.核对依据: Blood Glucose Test · MedlinePlus (NIH) (2024); Prothrombin time (PT) · MedlinePlus (NIH) (2025)

答案

D · Glucose 48 mg/dL (2.7 mmol/L) in a patient who had insulin an hour ago
7.临床护理

答案: D · Blood cultures

为什么是这个答案

Blood cultures taken before antibiotics are more likely to grow the organism, which allows targeted treatment later. Antibiotics should still be given promptly and must not be delayed.

答案

D · Blood cultures
8.临床护理

答案: B · 立即隔离，采取接触防护，并送检粪便标本

为什么是这个答案

原因不明的腹泻可能是感染性的，例如艰难梭菌或诺如病毒。及时隔离和检测可以保护其他患者。

答案

B · 立即隔离，采取接触防护，并送检粪便标本
9.内外科护理：心血管与呼吸

答案: A · Use a mouthpiece or protect the eyes from the mist

为什么是这个答案

Ipratropium is an antimuscarinic bronchodilator. Mist escaping from a face mask can reach the eyes, dilate the pupil and trigger acute angle-closure glaucoma in susceptible patients. A mouthpiece or eye protection reduces the risk.

答案

A · Use a mouthpiece or protect the eyes from the mist
10.内外科护理：心血管与呼吸

答案: C · A low-dose opioid with a hand-held fan and calm positioning

为什么是这个答案

Low-dose oral opioids can ease refractory breathlessness in advanced disease. A fan blowing air across the face, upright positioning, breathing techniques and anxiety management also help. Oxygen is used only if it relieves symptoms or corrects hypoxaemia.

答案

C · A low-dose opioid with a hand-held fan and calm positioning
11.内外科护理：神经、内分泌与肾脏

答案: B · The injury is incomplete, which suggests a better chance of recovery

为什么是这个答案

Preserved sensation or movement in the lowest sacral segments (sacral sparing) means the injury is incomplete. Incomplete injuries have a much better chance of some functional recovery.

答案

B · The injury is incomplete, which suggests a better chance of recovery
12.内外科护理：神经、内分泌与肾脏

答案: B · Secondary hypothyroidism

为什么是这个答案

When the pituitary cannot make enough TSH, the thyroid is not stimulated, so both TSH and free T4 are low. In primary thyroid failure, TSH is high. In secondary hypothyroidism, free T4, not TSH, is used to guide the dose.

答案

B · Secondary hypothyroidism
13.内外科护理：消化、围手术期与肿瘤

答案: D · Post-dural puncture headache

为什么是这个答案

CSF leaking through the dural puncture lowers pressure and causes a positional headache. Fluids, simple analgesia and caffeine may help, and the anaesthetist is informed; an epidural blood patch is sometimes needed.

答案

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

答案: A · Faecal impaction with overflow

为什么是这个答案

Overflow diarrhoea occurs when liquid stool leaks around impacted faeces. Antidiarrhoeal drugs would worsen it; the nurse escalates for assessment, and treatment includes laxatives or enemas and review of the opioids.

答案

A · Faecal impaction with overflow

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