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 malnourished patient admitted with alcohol use disorder needs IV glucose. Which vitamin is given before or with it?

  1. AVitamin C (ascorbic acid)
  2. BVitamin D (calciferol)
  3. CThiamine (vitamin B1)
  4. DVitamin K (phytonadione)
2.优先排序与委派困难

A patient has a chest drain for a pneumothorax. The nurse sees constant bubbling in the water-seal chamber. What does this most likely mean?

  1. AAn air leak in the patient or the system that needs checking
  2. BThe drain is working normally and no action is needed
  3. CThe lung has fully re-expanded, so the drain is ready to come out
  4. DThe suction is set too low and needs to be turned up
3.感染控制与患者安全中等

A child has swallowed a button battery. Why is this urgent?

  1. AIt always passes through the gut without harm
  2. BIt can burn through the lining of the esophagus within hours
  3. CIt is only harmful if several batteries are swallowed
  4. DThe only risk is poisoning from heavy metals years later
4.感染控制与患者安全困难

A patient’s cardiac monitor alarms often because of artifact, and a colleague suggests turning the alarm off. What is the best response?

  1. ADisconnect the monitor overnight so the patient can sleep
  2. BTurn the alarm volume down as low as it will go
  3. CKeep the alarm on, fix the cause such as electrode placement, and adjust limits only per policy
  4. DTurn the alarm off and check the monitor screen at the nurses’ station every hour instead
5.实验室检查值与电解质中等

A patient on a heparin infusion has blood in the urine and an aPTT far above the target. The nurse stops the infusion and informs the provider. Which antidote should the nurse anticipate?

  1. AProtamine sulfate
  2. BNaloxone
  3. CVitamin K (phytonadione)
  4. DCalcium gluconate
6.实验室检查值与电解质困难

A patient with a round face, central weight gain and purple stretch marks has a glucose of 210 mg/dL (11.7 mmol/L) and a potassium of 3.1 mEq/L. Which condition fits best?

  1. AHypothyroidism
  2. BAdrenal insufficiency
  3. CDiabetes insipidus
  4. DCushing syndrome
7.临床护理中等

一名意识不清的糖尿病患者血糖为 2.1 mmol/L，且没有静脉通路。可以给予什么？

  1. A皮下注射胰岛素
  2. B肌内注射胰高血糖素
  3. C口服果汁
  4. D口服葡萄糖片
8.临床护理困难

一名长期饥饿后接受肠内管饲的患者出现低磷、低钾和心律失常。最可能是什么？

  1. A再喂养综合征
  2. B倾倒综合征
  3. C甲状腺功能亢进
  4. D糖尿病酮症酸中毒
9.内外科护理：心血管与呼吸中等

Where is the V1 electrode placed for a 12-lead ECG?

  1. AOver the left nipple
  2. BJust below the left collarbone
  3. CThe fifth intercostal space in the mid-axillary line
  4. DThe fourth intercostal space just right of the sternum
10.内外科护理：心血管与呼吸困难

Four surgical patients need VTE prevention. For which patient is mechanical prophylaxis alone most appropriate?

  1. AA patient with cancer having bowel surgery
  2. BA patient who had a brain haemorrhage two days ago
  3. CAn obese patient after hip surgery
  4. DA patient after an uncomplicated knee replacement
11.内外科护理：神经、内分泌与肾脏中等

Which symptoms are typical of hypokalaemia?

  1. ATingling lips and facial twitching
  2. BExcess thirst and very high glucose
  3. CMuscle weakness, cramps and palpitations
  4. DHeat intolerance and weight loss
12.内外科护理：神经、内分泌与肾脏困难

On the first day after a kidney transplant, urine output suddenly falls from 200 mL/h to 10 mL/h. What should the nurse check first?

  1. AThe patient's blood glucose level
  2. BThat the catheter is not blocked or kinked
  3. CThe patient's temperature and pulse
  4. DWhether the patient has eaten
13.内外科护理：消化、围手术期与肿瘤中等

哪项饮食建议可降低新回肠造口堵塞的风险？

  1. A喝很少的水以使排出物变稠
  2. B不怎么咀嚼就快速吞咽食物
  3. C第一天起就吃大量坚果和种子
  4. D充分咀嚼，并缓慢引入含纤维的食物
14.内外科护理：消化、围手术期与肿瘤困难

While a central line is disconnected, a patient suddenly becomes breathless with chest pain and hypotension. Air embolism is suspected. What should the nurse do first?

  1. AClamp the line, lie the patient left side down, head low; give oxygen
  2. BSit the patient fully upright and flush the line
  3. CRemove the central line straight away and leave the site open to the air
  4. DGive the patient a drink and observe for an hour

3溶液

1.优先排序与委派

答案: C · Thiamine (vitamin B1)

为什么是这个答案

Thiamine deficiency is common in heavy alcohol use, and giving glucose without thiamine can trigger Wernicke encephalopathy. Thiamine is given before or with glucose.

答案

C · Thiamine (vitamin B1)
2.优先排序与委派

答案: A · An air leak in the patient or the system that needs checking

为什么是这个答案

Continuous bubbling in the water-seal chamber signals an air leak. The nurse checks the connections from the patient to the drain and reports a leak that cannot be fixed.

答案

A · An air leak in the patient or the system that needs checking
3.感染控制与患者安全

答案: B · It can burn through the lining of the esophagus within hours

为什么是这个答案

A button battery lodged in the esophagus can cause severe chemical burns within a few hours, so the child needs emergency assessment and often removal. It should never be treated as harmless.

答案

B · It can burn through the lining of the esophagus within hours
4.感染控制与患者安全

答案: C · Keep the alarm on, fix the cause such as electrode placement, and adjust limits only per policy

为什么是这个答案

Disabling alarms is a known cause of missed deterioration. Alarm fatigue is reduced by fixing causes such as poor skin preparation or old electrodes and by setting individual limits according to orders and policy.

答案

C · Keep the alarm on, fix the cause such as electrode placement, and adjust limits only per policy
6.实验室检查值与电解质

答案: D · Cushing syndrome

为什么是这个答案

Excess cortisol raises glucose, causes central obesity, a round face and purple striae, and has some mineralocorticoid effect that lowers potassium. Adrenal insufficiency causes low glucose and high potassium.核对依据: Hypercortisolism (Cushing Syndrome) · StatPearls (NCBI Bookshelf) (2025); Hypokalemia · StatPearls (NCBI Bookshelf) (2025)

答案

D · Cushing syndrome
7.临床护理

答案: B · 肌内注射胰高血糖素

为什么是这个答案

对意识不清的低血糖患者，口服治疗有误吸风险。肌注胰高血糖素可释放肝糖原；如有静脉通路则静脉给予葡萄糖。

答案

B · 肌内注射胰高血糖素
8.临床护理

答案: A · 再喂养综合征

为什么是这个答案

再喂养综合征是恢复进食时磷、钾和镁迅速转移进入细胞所致。高危患者应缓慢开始，并监测电解质和补充硫胺素。

答案

A · 再喂养综合征
9.内外科护理：心血管与呼吸

答案: D · The fourth intercostal space just right of the sternum

为什么是这个答案

V1 is placed in the fourth intercostal space at the right sternal edge, and V2 at the left sternal edge. V4 is in the fifth intercostal space in the mid-clavicular line, and V6 in the mid-axillary line at the same level. Wrong placement can mimic or hide changes.

答案

D · The fourth intercostal space just right of the sternum
10.内外科护理：心血管与呼吸

答案: B · A patient who had a brain haemorrhage two days ago

为什么是这个答案

When bleeding risk is high, such as after recent intracranial haemorrhage, mechanical methods (intermittent pneumatic compression) are used instead of anticoagulants until it is safe. The other patients are at high VTE risk and would usually receive pharmacological prophylaxis unless contraindicated.

答案

B · A patient who had a brain haemorrhage two days ago
11.内外科护理：神经、内分泌与肾脏

答案: C · Muscle weakness, cramps and palpitations

为什么是这个答案

Low potassium causes muscle weakness, cramps, constipation and arrhythmias. ECG changes include flattened T waves and U waves. Tingling and twitching suggest low calcium.

答案

C · Muscle weakness, cramps and palpitations
12.内外科护理：神经、内分泌与肾脏

答案: B · That the catheter is not blocked or kinked

为什么是这个答案

A sudden drop in output after transplant may be caused by a blocked catheter, often from clots. The nurse checks the tubing and may flush the catheter per protocol, and then escalates urgently, because vascular thrombosis or rejection are also possible.

答案

B · That the catheter is not blocked or kinked
13.内外科护理：消化、围手术期与肿瘤

答案: D · 充分咀嚼，并缓慢引入含纤维的食物

为什么是这个答案

坚果、甜玉米、干果和水果皮等含纤维的食物可形成团块，堵塞狭窄的造口。彻底咀嚼、缓慢引入这些食物和饮用足够的水可降低风险。堵塞的症状包括绞痛、造口肿胀和无排出物。

答案

D · 充分咀嚼，并缓慢引入含纤维的食物
14.内外科护理：消化、围手术期与肿瘤

答案: A · Clamp the line, lie the patient left side down, head low; give oxygen

为什么是这个答案

Air can enter an open central line. Clamping stops more air entering; the left lateral, head-down position may keep air in the right heart away from the pulmonary outflow. High-flow oxygen and emergency help are given.

答案

A · Clamp the line, lie the patient left side down, head low; give oxygen

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