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 young adult has just started an SSRI antidepressant for major depression. What should the nurse monitor most closely in the first weeks?

  1. AHair growth and skin color
  2. BWeight loss from too much appetite
  3. CThoughts of suicide or self-harm
  4. DRising blood glucose levels
2.优先排序与委派困难

After a head injury, a patient has clear fluid dripping from the nose. Which action should the nurse avoid?

  1. APlacing a loose gauze under the nose
  2. BInforming the provider about the drainage
  3. CInserting a tube or suction catheter through the nose
  4. DChecking the fluid for glucose or a halo sign on gauze
3.感染控制与患者安全中等

A patient walking with a gait belt suddenly starts to fall. What should the nurse do?

  1. ALet go of the belt and run to call for help
  2. BGrab the patient under both arms and try hard to keep them standing up
  3. CPull the patient backwards quickly toward the bed
  4. DHold the belt, widen the stance and ease the patient gently to the floor
4.感染控制与患者安全困难

一名活动性肺结核患者要求访客进来探视。最佳回应是什么？

  1. A解释风险，限制探视，并教访客使用所提供的防护
  2. B为了支持患者，让任何访客不加任何预防措施地进入
  3. C请访客站在敞开的门口，而不进入房间
  4. D永久禁止一切接触，包括电话
5.实验室检查值与电解质中等

A pregnant woman's blood type is O Rh-negative, and her antibody screen (indirect Coombs test) is negative. What is usually offered at about 28 weeks?

  1. AA transfusion of group O Rh-positive red cells
  2. BAn IV dose of vitamin K given for the fetus
  3. CAnti-D immunoglobulin (Rho(D) immune globulin)
  4. DDaily oral iron and folic acid supplements only
6.实验室检查值与电解质困难

A patient with acute kidney injury after severe dehydration has a rising creatinine. Which urine findings support a prerenal cause rather than acute tubular necrosis (ATN)?

  1. ARed cell casts with heavy protein loss in the urine
  2. BWhite cell casts with positive nitrites on the dipstick
  3. CLow urine sodium and concentrated urine with a high specific gravity
  4. DHigh urine sodium and dilute urine with muddy brown granular casts
7.临床护理中等

How should a nurse communicate with a patient who has impaired hearing?

  1. ATalk to the patient's relative instead of to the patient directly
  2. BSpeak very quickly to save time
  3. CFace the patient, speak clearly and reduce background noise
  4. DShout loudly from the end of the bed so they can hear
8.临床护理困难

A patient with suspected appendicitis says the pain suddenly eased, but an hour later has pain all over the abdomen, a rigid abdomen and a fever. What is most likely?

  1. AThe appendicitis has resolved without treatment
  2. BThe analgesia has started working
  3. CThe patient has developed gastroenteritis
  4. DThe appendix has perforated, causing peritonitis
9.内外科护理：心血管与呼吸中等

Which ECG change is classically linked with hyperkalaemia?

  1. ATall, peaked T waves
  2. BDelta waves before the QRS
  3. CProminent U waves
  4. DA sawtooth baseline
10.内外科护理：心血管与呼吸困难

A patient on spironolactone and an ACE inhibitor has a potassium of 6.8 mmol/L (6.8 mEq/L) with peaked T waves. What is usually given first to protect the heart?

  1. AOral potassium supplements
  2. BA dose of digoxin
  3. CAn IV furosemide bolus as the only treatment
  4. DIntravenous calcium gluconate or chloride
11.内外科护理：神经、内分泌与肾脏中等

哪项护理措施有助于预防颅内压升高？

  1. A鼓励每小时用力咳嗽
  2. B预防便秘，并分散安排护理操作
  3. C把所有护理和吸痰集中在一次长时间操作中
  4. D让患者平躺，髋部屈曲成锐角
12.内外科护理：神经、内分泌与肾脏困难

A patient with trigeminal neuralgia has lost weight and has poor oral hygiene. Which plan is most appropriate?

  1. AOffer soft, lukewarm food and advise chewing on the unaffected side
  2. BTell the patient to stop brushing their teeth completely
  3. CEncourage hard, crunchy foods to strengthen the jaw muscles
  4. DAdvise very hot drinks to relax the facial nerves
13.内外科护理：消化、围手术期与肿瘤中等

Why is a gastrostomy tube with an internal bumper usually advanced and rotated regularly once the tract has healed?

  1. ATo check that the patient is still hungry
  2. BTo stop the inner bumper becoming buried in the stomach wall
  3. CTo make the tube longer as the patient grows or gains weight
  4. DTo remove any feed left in the stomach
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. ANormal stool pattern on opioids
  2. BFaecal impaction with overflow
  3. CAcute infective gastroenteritis
  4. DA flare of ulcerative colitis

3溶液

1.优先排序与委派

答案: C · Thoughts of suicide or self-harm

为什么是这个答案

In the early weeks of antidepressant treatment, especially in young people, suicidal thoughts may increase. Patients and families are taught to report them at once.

答案

C · Thoughts of suicide or self-harm
2.优先排序与委派

答案: C · Inserting a tube or suction catheter through the nose

为什么是这个答案

Clear nasal drainage after a head injury can be cerebrospinal fluid from a basal skull fracture. Nasal tubes could enter the brain and introduce infection, so they are avoided.

答案

C · Inserting a tube or suction catheter through the nose
3.感染控制与患者安全

答案: D · Hold the belt, widen the stance and ease the patient gently to the floor

为什么是这个答案

The nurse keeps hold of the gait belt, takes a wide base of support and slides the patient down along their own leg to the floor, protecting the head. This controls the fall and protects the nurse’s back.

答案

D · Hold the belt, widen the stance and ease the patient gently to the floor
4.感染控制与患者安全

答案: A · 解释风险，限制探视，并教访客使用所提供的防护

为什么是这个答案

应依据规定限制探视，辅以教育和防护，患者仍留在关闭的负压病房中。在敞开的门口探视会破坏负压。

答案

A · 解释风险，限制探视，并教访客使用所提供的防护
5.实验室检查值与电解质

答案: C · Anti-D immunoglobulin (Rho(D) immune globulin)

为什么是这个答案

An Rh-negative mother can form anti-D antibodies if Rh-positive fetal blood enters her circulation, which can cause hemolytic disease in a later pregnancy. Anti-D immunoglobulin at about 28 weeks and after delivery of an Rh-positive baby prevents this sensitization.核对依据: Red Blood Cell Antibody Screen · MedlinePlus (NIH) (2025); Hemolytic disease of the newborn · MedlinePlus (NIH) (2025)

答案

C · Anti-D immunoglobulin (Rho(D) immune globulin)
6.实验室检查值与电解质

答案: C · Low urine sodium and concentrated urine with a high specific gravity

为什么是这个答案

In prerenal AKI the tubules are intact, so they keep sodium and water, giving a low urine sodium and concentrated urine. In ATN the damaged tubules cannot do this, so urine sodium is high, the urine is dilute and muddy brown casts appear.核对依据: Urine specific gravity test · MedlinePlus (NIH) (2025)

答案

C · Low urine sodium and concentrated urine with a high specific gravity
7.临床护理

答案: C · Face the patient, speak clearly and reduce background noise

为什么是这个答案

Facing the patient in good light, speaking clearly at a normal pace, checking hearing aids and reducing noise improves communication. Written information can also help.

答案

C · Face the patient, speak clearly and reduce background noise
8.临床护理

答案: D · The appendix has perforated, causing peritonitis

为什么是这个答案

Perforation may briefly relieve the pain as pressure in the appendix falls, followed by generalised peritonitis. This needs urgent surgical review, IV fluids and antibiotics.

答案

D · The appendix has perforated, causing peritonitis
9.内外科护理：心血管与呼吸

答案: A · Tall, peaked T waves

为什么是这个答案

Rising potassium causes tall, tented T waves, then a flattened P wave, a prolonged PR interval and a widening QRS that can progress to ventricular fibrillation or asystole. U waves suggest hypokalaemia; a sawtooth baseline is atrial flutter.

答案

A · Tall, peaked T waves
10.内外科护理：心血管与呼吸

答案: D · Intravenous calcium gluconate or chloride

为什么是这个答案

Severe hyperkalaemia with ECG changes is an emergency. IV calcium stabilises the myocardium within minutes. Insulin with glucose and nebulised salbutamol shift potassium into cells, and the cause (here spironolactone and the ACE inhibitor) is stopped. Cardiac monitoring is essential.

答案

D · Intravenous calcium gluconate or chloride
11.内外科护理：神经、内分泌与肾脏

答案: B · 预防便秘，并分散安排护理操作

为什么是这个答案

用力排便、咳嗽、长时间吸痰、髋部屈曲、疼痛和躁动都会使颅内压升高。使用大便软化剂、充分镇痛，以及分散安排护理使颅内压能在两次操作之间恢复，有助于使其保持较低水平。

答案

B · 预防便秘，并分散安排护理操作
12.内外科护理：神经、内分泌与肾脏

答案: A · Offer soft, lukewarm food and advise chewing on the unaffected side

为什么是这个答案

Patients may avoid eating and brushing their teeth because these trigger attacks. Soft, lukewarm food, chewing on the unaffected side, gentle oral care and effective drug treatment help maintain nutrition and hygiene.

答案

A · Offer soft, lukewarm food and advise chewing on the unaffected side
13.内外科护理：消化、围手术期与肿瘤

答案: B · To stop the inner bumper becoming buried in the stomach wall

为什么是这个答案

Buried bumper syndrome occurs when the internal fixator embeds in the gastric wall. Following local guidance, the tube is gently advanced, rotated and returned once healed, and the external fixator is kept slightly loose.

答案

B · To stop the inner bumper becoming buried in the stomach wall
14.内外科护理：消化、围手术期与肿瘤

答案: B · 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

B · Faecal impaction with overflow

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