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 has heart failure. Which instruction about daily weights is best to give the nursing assistant?

  1. A“Only weigh him if his ankles look more swollen than they did yesterday afternoon.”
  2. B“Weigh him each morning before breakfast, on the same scale, and tell me the result.”
  3. C“Weigh him at any time today, on whichever scale is free.”
  4. D“Weigh him after lunch, fully dressed, with his shoes on.”
2.优先排序与委派困难

一名 LPN/LVN 报告说一名稳定的患者现在出现新的胸痛。RN 应怎么做？

  1. A亲自评估患者并决定下一步
  2. B让护理助理做心电图并等待结果
  3. C告诉 LPN/LVN 不经评估就给予按需使用的硝酸甘油
  4. D让 LPN/LVN 处理，并在班次结束时回报
3.感染控制与患者安全中等

Which technique is correct when collecting a wound culture?

  1. AClean the wound with sterile saline first, then swab clean tissue
  2. BSwab the old pus on the dressing that was just removed from the wound
  3. CCollect the sample only after antibiotics have been started
  4. DUse one swab to sample two different wounds
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. AReprogram the pump and finish the shift before reporting
  2. BStop the infusion and check the patient’s blood glucose
  3. CLeave it running and check the glucose at the next routine time
  4. DDouble the rate to correct for the error
5.实验室检查值与电解质中等

A patient with hyperkalemia received IV regular insulin with dextrose. Which result must the nurse monitor closely over the next hours?

  1. ASerum sodium, because it rises quickly
  2. BBlood glucose, because hypoglycemia can occur
  3. CHemoglobin, because insulin causes red cell loss
  4. DSerum calcium, because it falls sharply
6.实验室检查值与电解质困难

A patient with SIADH is on fluid restriction. Which task can the RN delegate to unlicensed assistive personnel (UAP), such as a nursing or healthcare assistant?

  1. ATeaching the reasons for fluid restriction
  2. BMeasuring and recording intake and output
  3. CAssessing the patient for new confusion
  4. DDeciding when to recheck the sodium level
7.临床护理中等

Which oxygen device delivers a precise, fixed concentration of oxygen?

  1. AVenturi mask
  2. BNon-rebreathe mask
  3. CNasal cannula
  4. DSimple face mask
8.临床护理困难

An older man has sudden severe abdominal and back pain, is hypotensive and has a pulsating mass in the abdomen. What should be suspected?

  1. AA ruptured abdominal aortic aneurysm
  2. BAcute gastritis from anti-inflammatory drugs
  3. CMusculoskeletal back pain
  4. DRenal colic from a kidney stone
9.内外科护理：心血管与呼吸中等

Suspected pulmonary TB is being investigated. How are sputum samples usually collected?

  1. AA swab from the nose only
  2. BSeveral samples, ideally including early-morning sputum
  3. COne sample of saliva collected at any time of the day
  4. DA single sample after the first week of treatment
10.内外科护理：心血管与呼吸困难

一名呼吸困难的患者使用 15 L/min 的非重复呼吸面罩，储氧袋在每次呼吸时都完全塌陷。护士应怎么做？

  1. A将流量减至 2 L/min 以阻止储氧袋塌陷
  2. B取下储氧袋，因为面罩没有它也能工作
  3. C不处理，因为储氧袋塌陷说明密封良好
  4. D检查氧气供应和流量，使储氧袋保持充盈
11.内外科护理：神经、内分泌与肾脏中等

一名患者醒来时出现卒中症状。他们 23:00 上床时一切正常，06:30 醒来。哪个时间被用作发病时间？

  1. A到达医院的时间
  2. B23:00，即最后一次已知正常的时间
  3. C06:30，即首次发现症状的时间
  4. D做 CT 扫描的时间
12.内外科护理：神经、内分泌与肾脏困难

A man with chronic urinary retention is catheterised. Over the next hours he passes very large volumes of urine. What is the main nursing concern?

  1. AFluid and electrolyte loss from post-obstructive diuresis
  2. BA rise in blood glucose from the urine
  3. CA urinary infection caused by the high flow of urine
  4. DRupture of the bladder from the catheter
13.内外科护理：消化、围手术期与肿瘤中等

Why are antimotility drugs such as loperamide avoided in C. difficile infection?

  1. AThey make the stool sample test positive falsely
  2. BThey may keep toxin in the bowel and risk toxic megacolon
  3. CThey cause serious liver failure in most patients who take them
  4. DThey kill the normal bowel bacteria
14.内外科护理：消化、围手术期与肿瘤困难

During a nerve block, a patient reports a metallic taste and ringing in the ears, then has a seizure. Besides calling for help and supporting the airway, which specific treatment is given?

  1. AIV dantrolene
  2. BIV naloxone
  3. CIV glucose 50%
  4. DIV lipid emulsion

3溶液

1.优先排序与委派

答案: B · “Weigh him each morning before breakfast, on the same scale, and tell me the result.”

为什么是这个答案

Daily weights are measured at the same time, on the same scale and in similar clothing so that changes show real fluid gain. A quick rise in weight can be an early sign of worsening heart failure.

答案

B · “Weigh him each morning before breakfast, on the same scale, and tell me the result.”
2.优先排序与委派

答案: A · 亲自评估患者并决定下一步

为什么是这个答案

当稳定的患者出现新问题时，RN 应评估患者，因为患者现在可能不稳定。然后 RN 决定干预措施和上报，可能包括心电图和处方的硝酸甘油。

答案

A · 亲自评估患者并决定下一步
3.感染控制与患者安全

答案: A · Clean the wound with sterile saline first, then swab clean tissue

为什么是这个答案

Old exudate contains surface bacteria that may not be causing the infection. The wound is cleaned with sterile saline and then swabbed over clean, viable tissue, ideally before antibiotics start.

答案

A · Clean the wound with sterile saline first, then swab clean tissue
4.感染控制与患者安全

答案: B · 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

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

答案: B · Blood glucose, because hypoglycemia can occur

为什么是这个答案

Insulin shifts potassium into cells but also lowers glucose, and hypoglycemia can occur hours later, especially in kidney failure. Glucose is checked frequently, and potassium is rechecked, as the effect lasts only a few hours.核对依据: High potassium level · MedlinePlus (NIH) (2025)

答案

B · Blood glucose, because hypoglycemia can occur
6.实验室检查值与电解质

答案: B · Measuring and recording intake and output

为什么是这个答案

UAP can measure and record intake and output and weigh the patient, then report the values to the RN. Assessing mental status, teaching and making decisions about laboratory monitoring need nursing judgment and remain with the RN.

答案

B · Measuring and recording intake and output
7.临床护理

答案: A · Venturi mask

为什么是这个答案

A Venturi mask entrains a set amount of room air, giving a fixed oxygen percentage regardless of the patient's breathing pattern. This makes it useful for patients at risk of hypercapnia.

答案

A · Venturi mask
8.临床护理

答案: A · A ruptured abdominal aortic aneurysm

为什么是这个答案

A ruptured AAA classically presents with pain, shock and a pulsatile mass. It is a surgical emergency needing immediate senior help and transfer to theatre.

答案

A · A ruptured abdominal aortic aneurysm
9.内外科护理：心血管与呼吸

答案: B · Several samples, ideally including early-morning sputum

为什么是这个答案

Usually three sputum samples, including an early-morning sample, are sent for smear microscopy, culture and molecular testing. Deep coughed sputum, not saliva, is needed. Samples are collected before treatment where possible and in a way that limits exposure to others.

答案

B · Several samples, ideally including early-morning sputum
10.内外科护理：心血管与呼吸

答案: D · 检查氧气供应和流量，使储氧袋保持充盈

为什么是这个答案

储氧袋应在戴面罩之前充满，并在吸气时至少保持部分充盈。储氧袋完全塌陷意味着患者没有获得足够的氧气，可能在吸入室内空气。应检查供氧和流量，若患者仍缺氧则上报。

答案

D · 检查氧气供应和流量，使储氧袋保持充盈
11.内外科护理：神经、内分泌与肾脏

答案: B · 23:00，即最后一次已知正常的时间

为什么是这个答案

对于“醒后卒中”，发病时间取患者最后一次已知正常的时间，因为卒中可能发生在此后任何时刻。这常使患者超出标准溶栓时间窗，不过高级影像学有时可识别出仍可能获益的患者。

答案

B · 23:00，即最后一次已知正常的时间
12.内外科护理：神经、内分泌与肾脏

答案: A · Fluid and electrolyte loss from post-obstructive diuresis

为什么是这个答案

After relief of chronic obstruction, the kidneys may pass large volumes of urine and salt. Hypovolaemia and electrolyte problems can follow. Strict fluid balance, blood pressure checks and electrolyte monitoring are needed.

答案

A · Fluid and electrolyte loss from post-obstructive diuresis
13.内外科护理：消化、围手术期与肿瘤

答案: B · They may keep toxin in the bowel and risk toxic megacolon

为什么是这个答案

Slowing the bowel can increase toxin contact and the risk of colonic dilatation (toxic megacolon). Treatment is an oral antibiotic such as vancomycin or fidaxomicin, stopping unnecessary antibiotics and replacing fluids.

答案

B · They may keep toxin in the bowel and risk toxic megacolon
14.内外科护理：消化、围手术期与肿瘤

答案: D · IV lipid emulsion

为什么是这个答案

These are signs of local anaesthetic systemic toxicity. The injection is stopped, help is called, the airway is secured and seizures are treated. IV lipid emulsion is the specific treatment, especially if the circulation is affected.

答案

D · IV lipid emulsion

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