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

在病房发生心脏骤停时，确认患者无反应且没有正常呼吸之后，首先做什么？

  1. A呼救并开始胸外按压
  2. B在呼救之前先找到患者的病历，核对复苏状态
  3. C给两次人工呼吸，然后检查脉搏一分钟
  4. D测量血压
2.优先排序与委派困难

一名头部受伤并伴有腿部骨折的患者正在接受监测。哪项发现是优先事项？

  1. A格拉斯哥昏迷评分从 15 分降至 12 分
  2. B患者要求吃点东西
  3. C肘部有一处小擦伤
  4. D尽管刚用过镇痛药，腿痛仍为 6/10
3.感染控制与患者安全中等

Before a defibrillator shock is delivered, what must the person operating it do?

  1. AKeep the oxygen mask on the patient’s face, held against the chest
  2. BHold the patient’s hand to keep them still
  3. CCall “all clear” and check that nobody is touching the patient or bed
  4. DAsk a colleague to hold the paddles in place
4.感染控制与患者安全困难

A hospital will introduce new infusion pumps and wants to find out how the process could fail before any harm occurs. Which method fits best?

  1. AAn incident report for each new pump
  2. BA morbidity and mortality meeting
  3. CRoot cause analysis (RCA) of the new pumps
  4. DFailure mode and effects analysis (FMEA)
5.实验室检查值与电解质中等

一名患者血细胞比容 54%，BUN 高，尿比重 1.034。这种模式提示什么？

  1. A脱水伴血液浓缩
  2. B肾衰竭伴尿液稀释
  3. C急性失血伴稀释
  4. D液体过载
6.实验室检查值与电解质困难

The nurse teaches a patient with iron-deficiency anemia who is starting oral iron. Which statement shows a need for further teaching?

  1. A"My stools may look darker while I take the tablets"
  2. B"I'll keep the tablets out of reach of the children"
  3. C"I can take it with orange juice to help absorption"
  4. D"I'll take my iron tablet with a big glass of milk"
7.临床护理中等

A spontaneously breathing patient is critically ill and hypoxic. Which oxygen delivery gives the highest concentration?

  1. AVenturi mask set to 24%
  2. BNasal cannula at 2 L/min
  3. CSimple face mask at 5 L/min with the patient sitting up
  4. DNon-rebreathe mask with reservoir bag at 15 L/min
8.临床护理困难

Why must blood samples for a cross-match be labelled at the bedside immediately after they are taken?

  1. ATo keep the sample warm so the cells do not break down in transit
  2. BTo speed up the laboratory's computer system and reduce the waiting time
  3. CTo prevent "wrong blood in tube" errors that can cause fatal reactions
  4. DTo let the patient sign the label
9.内外科护理：心血管与呼吸中等

一名高血压患者服用氨氯地平。护士最可能观察到哪种副作用？

  1. A高钾血症
  2. B踝部肿胀
  3. C哮鸣音
  4. D干咳、咽痒
10.内外科护理：心血管与呼吸困难

A patient who has had a total laryngectomy becomes breathless and needs oxygen. How should it be given?

  1. AVia nasal cannula at 2 L/min
  2. BVia a standard face mask over the nose and mouth
  3. CVia a mask or humidified device over the neck stoma
  4. DVia a non-rebreather mask over the mouth only
11.内外科护理：神经、内分泌与肾脏中等

When the nurse squeezes the trapezius muscle, the patient brings a hand up above the collarbone towards the stimulus. Which GCS motor score is this?

  1. A6, obeys commands
  2. B4, withdraws from pain
  3. C3, abnormal flexion
  4. D5, localises to pain
12.内外科护理：神经、内分泌与肾脏困难

A patient has fever, confusion, odd behaviour and a new seizure. Herpes simplex encephalitis is suspected. Which drug is usually started straight away?

  1. AIV aciclovir
  2. BOral prednisolone
  3. COral amoxicillin
  4. DIV insulin
13.内外科护理：消化、围手术期与肿瘤中等

Which finding means a patient is usually ready to leave recovery for the ward?

  1. AAwake, with a clear airway, stable observations and controlled pain
  2. BPain score 9/10 and vomiting repeatedly
  3. CStill drowsy and needing a jaw thrust to breathe
  4. DSystolic BP falling steadily over the last hour, with a rising pulse rate
14.内外科护理：消化、围手术期与肿瘤困难

A patient with suspected appendicitis says the pain suddenly eased, but an hour later has a temperature of 38.9 °C, a rigid abdomen and a pulse of 118/min. What does this suggest?

  1. ASimple constipation that needs a laxative
  2. BThe appendicitis has settled by itself
  3. CPerforation with peritonitis
  4. DA side effect of the analgesia given

3溶液

1.优先排序与委派

答案: A · 呼救并开始胸外按压

为什么是这个答案

呼救（骤停团队和除颤器）并立即开始高质量的按压。长时间检查脉搏、延误或测量血压都是浪费时间。如有可能，应事先知道复苏状态。

答案

A · 呼救并开始胸外按压
2.优先排序与委派

答案: A · 格拉斯哥昏迷评分从 15 分降至 12 分

为什么是这个答案

GCS 下降提示颅内压升高，可能致命，需要紧急上报。骨折疼痛也需要处理，但不像这样威胁生命。

答案

A · 格拉斯哥昏迷评分从 15 分降至 12 分
3.感染控制与患者安全

答案: C · Call “all clear” and check that nobody is touching the patient or bed

为什么是这个答案

Anyone touching the patient or bed could receive the shock. The operator announces “clear” and looks to confirm that nobody is in contact, and oxygen is moved away from the chest.

答案

C · Call “all clear” and check that nobody is touching the patient or bed
4.感染控制与患者安全

答案: D · Failure mode and effects analysis (FMEA)

为什么是这个答案

FMEA is a proactive method that looks at each step of a process, asks how it could fail and what the effect would be, and changes the process in advance. Root cause analysis is used after an event has happened.

答案

D · Failure mode and effects analysis (FMEA)
5.实验室检查值与电解质

答案: A · 脱水伴血液浓缩

为什么是这个答案

血浆水分的丢失使红细胞浓缩（血细胞比容升高）、尿液浓缩（比重高），BUN 升高。液体过载则会出现相反的模式。核对依据: Hematocrit Test · MedlinePlus (NIH) (2024); BUN (Blood Urea Nitrogen) · MedlinePlus (NIH) (2024)

答案

A · 脱水伴血液浓缩
6.实验室检查值与电解质

答案: D · "I'll take my iron tablet with a big glass of milk"

为什么是这个答案

Calcium in milk, as well as antacids and tea, reduces iron absorption, so iron should not be taken with them. Vitamin C improves absorption, dark stools are expected, and iron overdose is a serious poisoning risk in young children.核对依据: Iron deficiency anemia - Medical Encyclopedia · MedlinePlus (NIH) (2025); Iron in diet - Medical Encyclopedia · MedlinePlus (NIH) (2025)

答案

D · "I'll take my iron tablet with a big glass of milk"
7.临床护理

答案: D · Non-rebreathe mask with reservoir bag at 15 L/min

为什么是这个答案

A non-rebreathe mask with a filled reservoir at 15 L/min delivers a high oxygen concentration and is used first in critical illness. The dose is then titrated down to the target saturation.

答案

D · Non-rebreathe mask with reservoir bag at 15 L/min
8.临床护理

答案: C · To prevent "wrong blood in tube" errors that can cause fatal reactions

为什么是这个答案

A sample labelled with the wrong patient's details can lead to incompatible blood being issued. Labelling at the bedside after positive identification is a key transfusion safety step.

答案

C · To prevent "wrong blood in tube" errors that can cause fatal reactions
9.内外科护理：心血管与呼吸

答案: B · 踝部肿胀

为什么是这个答案

氨氯地平等二氢吡啶类钙通道阻滞剂扩张小动脉，使毛细血管压力升高，引起外周水肿、面部潮红和头痛。干咳是 ACE 抑制剂的典型副作用，哮鸣音则见于哮喘患者使用非选择性 β 受体阻滞剂时。

答案

B · 踝部肿胀
10.内外科护理：心血管与呼吸

答案: C · Via a mask or humidified device over the neck stoma

为什么是这个答案

A total laryngectomy separates the trachea from the upper airway, so the patient breathes only through the neck stoma. Oxygen and any rescue breaths must be given via the stoma. These patients are "neck breathers" and often carry an alert card.

答案

C · Via a mask or humidified device over the neck stoma
11.内外科护理：神经、内分泌与肾脏

答案: D · 5, localises to pain

为什么是这个答案

Localising to pain (5) means a purposeful movement towards the source of pain. Withdrawal (4) is pulling away, abnormal flexion (3) is decorticate posturing, and obeying commands (6) needs no pain at all. A central stimulus, such as a trapezius squeeze, is used to test for localising.

答案

D · 5, localises to pain
12.内外科护理：神经、内分泌与肾脏

答案: A · IV aciclovir

为什么是这个答案

Herpes simplex encephalitis is treatable but can cause severe brain damage. IV aciclovir is started as soon as it is suspected, without waiting for test results. Kidney function and hydration are monitored during treatment.

答案

A · IV aciclovir
13.内外科护理：消化、围手术期与肿瘤

答案: A · Awake, with a clear airway, stable observations and controlled pain

为什么是这个答案

Discharge criteria include a protected airway, adequate breathing and oxygen saturation, stable vital signs, acceptable pain and nausea control, and no active bleeding, as set by local recovery criteria.

答案

A · Awake, with a clear airway, stable observations and controlled pain
14.内外科护理：消化、围手术期与肿瘤

答案: C · Perforation with peritonitis

为什么是这个答案

Brief relief can occur when an inflamed appendix ruptures, followed by spreading peritonitis with fever, rigidity and tachycardia. This is a surgical emergency needing urgent review, IV fluids and antibiotics.

答案

C · Perforation with peritonitis

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