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 with severe neutropenia needs a room. Which roommate is the safest choice?

  1. AA patient with an infected, draining leg wound
  2. BA patient with C. difficile diarrhea
  3. CA patient after a knee replacement with no signs of infection
  4. DA patient with influenza
2.优先排序与委派困难

A patient with Guillain-Barré syndrome has weakness that is spreading up from the legs. Which assessment has the highest priority?

  1. ASkin condition over the heels
  2. BBreathing strength, such as vital capacity and the ability to cough
  3. CMuscle strength in the feet and ankles at the start of each morning
  4. DThe patient’s mood and coping
3.感染控制与患者安全中等

What is the main aim of purposeful hourly rounding?

  1. ATo count the patient’s medications every hour and check that none are missing
  2. BTo check pain, toileting, position and personal items before the patient needs to ask
  3. CTo replace the need for a call light
  4. DTo wake the patient every hour to check orientation
4.感染控制与患者安全困难

某病区把浓氯化钾药瓶放在病房备用药品柜中。为什么许多安全指南建议不要这样做？

  1. A氯化钾太贵，不适合作为病房常规备用药
  2. B氯化钾必须始终口服
  3. C误将未稀释的浓缩液给药可使心脏停搏
  4. D氯化钾药瓶开启后一天内就会过期
5.实验室检查值与电解质中等

A young adult with new diabetes has a very low C-peptide level. What does this suggest?

  1. AThe patient has high insulin resistance, as in type 2 diabetes
  2. BThe pancreas is making very little insulin, as in type 1 diabetes
  3. CThe kidneys are excreting all of the patient's insulin in urine
  4. DThe patient is injecting too much insulin and needs a lower dose
6.实验室检查值与电解质困难

A man of Mediterranean descent develops dark urine, jaundice and a falling hemoglobin a few days after eating fava beans. Which condition is most likely?

  1. ASickle cell crisis with vaso-occlusion
  2. BG6PD deficiency with acute hemolysis
  3. CVitamin B12 deficiency anemia
  4. DIron-deficiency anemia from poor diet
7.临床护理中等

A patient is admitted with cellulitis of the leg. Why might the nurse mark the edge of the redness on the skin?

  1. ATo monitor whether the infection is spreading or improving
  2. BTo help the patient find the sore area
  3. CTo mark the site for an injection
  4. DTo show the surgeon exactly where to make the incision
8.临床护理困难

Why can sepsis be missed in older adults?

  1. AThey may have no fever and present with confusion, falls or reduced mobility
  2. BOlder adults cannot develop sepsis because their immune system is weaker
  3. COlder adults always have a very high fever
  4. DBlood tests are not useful in older people
9.内外科护理：心血管与呼吸中等

After repair of an abdominal aortic aneurysm, which regular assessment helps detect a blocked graft or clots in the legs?

  1. ATesting the gag reflex every four hours after surgery
  2. BMeasuring the blood glucose every hour through the night
  3. CChecking the pupils' response to light
  4. DChecking leg pulses, colour, warmth and sensation
10.内外科护理：心血管与呼吸困难

A day after a myocardial infarction, a patient has frequent ventricular ectopic beats on the monitor. Which blood results should be checked first?

  1. APotassium and magnesium
  2. BAmylase and lipase
  3. CFerritin and vitamin B12
  4. DAlbumin and bilirubin
11.内外科护理：神经、内分泌与肾脏中等

How does the nurse test the facial nerve (VII)?

  1. AAsk them to raise the eyebrows, shut the eyes tightly and smile
  2. BTouch the forehead, cheek and chin with cotton wool
  3. CAsk the patient to stick out the tongue and move it from side to side
  4. DShine a light in each eye and check the pupil response
12.内外科护理：神经、内分泌与肾脏困难

A kidney transplant recipient has had vomiting and diarrhoea for two days. Why should the transplant team be contacted?

  1. AThe patient may not be absorbing their immunosuppressants
  2. BVomiting proves that rejection has already happened
  3. CThe kidney will start to produce far too much urine
  4. DThe tablets will make the vomiting stop
13.内外科护理：消化、围手术期与肿瘤中等

一名肝硬化患者因肝性脑病服用乳果糖。通常的目标是什么？

  1. A数天不排便
  2. B每周一次硬便
  3. C每天排两到三次软便
  4. D每天十次或更多水样便
14.内外科护理：消化、围手术期与肿瘤困难

A patient with a sacral pressure ulcer keeps sliding down the bed when the head is raised high. Which advice best reduces shear?

  1. AKeep the head of the bed at or below 30° if possible; use slide sheets
  2. BRaise the head of the bed to 90° and pull the patient up the bed by the arms
  3. CUse a dry sheet and drag the patient up the bed
  4. DSit the patient upright without any support for the feet

3溶液

1.优先排序与委派

答案: C · A patient after a knee replacement with no signs of infection

为什么是这个答案

A neutropenic patient cannot fight infection well, so the roommate must not have a transmissible infection. A clean postoperative patient is the safest choice; ideally the neutropenic patient has a single room.

答案

C · A patient after a knee replacement with no signs of infection
2.优先排序与委派

答案: B · Breathing strength, such as vital capacity and the ability to cough

为什么是这个答案

Guillain-Barré syndrome causes ascending weakness that can involve the respiratory muscles. Falling vital capacity or a weak cough can mean the patient needs ventilation, so breathing is monitored closely.

答案

B · Breathing strength, such as vital capacity and the ability to cough
3.感染控制与患者安全

答案: B · To check pain, toileting, position and personal items before the patient needs to ask

为什么是这个答案

Regular, planned rounding that addresses pain, toileting, positioning and possessions within reach reduces falls and call-light use. The call light stays within reach as well.

答案

B · To check pain, toileting, position and personal items before the patient needs to ask
4.感染控制与患者安全

答案: C · 误将未稀释的浓缩液给药可使心脏停搏

为什么是这个答案

浓氯化钾未经稀释或输注过快可使心脏停搏。把浓缩液从病房常规备用药中撤出，改用预混即用的输液袋，是广泛推荐的安全措施。

答案

C · 误将未稀释的浓缩液给药可使心脏停搏
5.实验室检查值与电解质

答案: B · The pancreas is making very little insulin, as in type 1 diabetes

为什么是这个答案

C-peptide is cleaved from proinsulin when insulin is made, so it reflects the body's own insulin production. A very low level suggests beta-cell loss, as in type 1 diabetes; in type 2 diabetes it is often normal or high early on.

答案

B · The pancreas is making very little insulin, as in type 1 diabetes
6.实验室检查值与电解质

答案: B · G6PD deficiency with acute hemolysis

为什么是这个答案

G6PD deficiency makes red cells vulnerable to oxidative damage. Fava beans, some drugs (such as primaquine and some sulfonamides) and infections can trigger acute hemolysis, with dark urine, jaundice and anemia. Triggers are avoided.

答案

B · G6PD deficiency with acute hemolysis
7.临床护理

答案: A · To monitor whether the infection is spreading or improving

为什么是这个答案

Marking the margin helps staff see whether the redness is spreading despite treatment, which may mean antibiotics need review. The limb is also elevated and observations monitored.

答案

A · To monitor whether the infection is spreading or improving
8.临床护理

答案: A · They may have no fever and present with confusion, falls or reduced mobility

为什么是这个答案

Older people may have a normal or low temperature and present with delirium, falls or general decline. Early warning scores and a high index of suspicion are important.

答案

A · They may have no fever and present with confusion, falls or reduced mobility
9.内外科护理：心血管与呼吸

答案: D · Checking leg pulses, colour, warmth and sensation

为什么是这个答案

After aortic surgery, distal pulses, skin colour, temperature, capillary refill, movement and sensation are checked often and compared with baseline. Loss of pulses, pallor or pain suggests graft occlusion or emboli and must be reported at once. Urine output is also monitored for renal perfusion.

答案

D · Checking leg pulses, colour, warmth and sensation
10.内外科护理：心血管与呼吸

答案: A · Potassium and magnesium

为什么是这个答案

Low potassium and low magnesium both increase ventricular irritability and the risk of VT and VF after an MI. They are checked and corrected, usually keeping potassium in the upper part of the normal range. The patient is also assessed for ischaemia and haemodynamic change.

答案

A · Potassium and magnesium
11.内外科护理：神经、内分泌与肾脏

答案: A · Ask them to raise the eyebrows, shut the eyes tightly and smile

为什么是这个答案

The facial nerve moves the muscles of the face. Asking the patient to raise the eyebrows, close the eyes, puff the cheeks and smile shows any weakness. Facial sensation is carried by the trigeminal nerve.

答案

A · Ask them to raise the eyebrows, shut the eyes tightly and smile
12.内外科护理：神经、内分泌与肾脏

答案: A · The patient may not be absorbing their immunosuppressants

为什么是这个答案

Vomiting and diarrhoea can reduce absorption of immunosuppressants, raising the risk of rejection, and dehydration can harm the graft. Tacrolimus levels can also rise with diarrhoea. The team may check levels and kidney function.

答案

A · The patient may not be absorbing their immunosuppressants
13.内外科护理：消化、围手术期与肿瘤

答案: C · 每天排两到三次软便

为什么是这个答案

乳果糖使结肠酸化并捕获氨，还能加快肠道转运。剂量应滴定至每天 2–3 次软便。过度腹泻可引起脱水和电解质紊乱，使脑病加重。

答案

C · 每天排两到三次软便
14.内外科护理：消化、围手术期与肿瘤

答案: A · Keep the head of the bed at or below 30° if possible; use slide sheets

为什么是这个答案

A high head position makes patients slide, causing shear on the sacrum. A lower head position when clinically possible, knee break or foot support, and slide sheets for moving reduce shear and friction.

答案

A · Keep the head of the bed at or below 30° if possible; use slide sheets

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