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。

新题目返回课程

在打印窗口中选择“另存为 PDF”，即可在设备上保存一份副本。

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

Which telephone call should a clinic nurse return first?

  1. AA parent of a 6-week-old with a temperature of 38.3 °C
  2. BAn adult who wants to move a routine blood test appointment
  3. CA parent of a 5-year-old with a runny nose for two days
  4. DAn adult asking for a repeat prescription for a statin
2.优先排序与委派困难

A patient is deteriorating quickly. The nurse has called the provider twice, but the provider has not come. What is the best action?

  1. AActivate the rapid response team
  2. BDocument the concern and continue routine care
  3. CAsk the patient’s family to call the provider
  4. DWait another hour and call the provider again
3.感染控制与患者安全中等

A patient has botulism after eating contaminated food. Which precautions are needed?

  1. AContact precautions
  2. BDroplet precautions
  3. CStandard precautions
  4. DAirborne precautions
4.感染控制与患者安全困难

A patient with pulmonary tuberculosis has been on treatment. Which findings usually allow airborne isolation to end?

  1. AOne negative chest x-ray after starting treatment
  2. BThe cough has stopped, even with no sputum tests
  3. CThe patient has been in hospital for one week and has taken every dose of medicine
  4. DThree negative sputum smears, clinical improvement and continued therapy
5.实验室检查值与电解质中等

一名已呕吐两天的患者 BUN 为 32 mg/dL（尿素 11.4 mmol/L），肌酐正常。最可能的原因是什么？

  1. A脱水
  2. B低蛋白饮食
  3. C肝衰竭
  4. D水过多
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. AAdrenal insufficiency
  2. BCushing syndrome
  3. CDiabetes insipidus
  4. DHypothyroidism
7.临床护理中等

Which side effect is associated with SGLT2 inhibitors such as dapagliflozin?

  1. ASevere weight gain and fluid retention
  2. BGenital fungal infections
  3. CBradycardia
  4. DHair loss
8.临床护理困难

一名临终患者意识不清，咽喉部分泌物引起嘈杂的咕噜样呼吸声。哪种处理是恰当的？

  1. A告诉家属患者正在窒息，需要机械通气
  2. B开始快速静脉补液，以稀释和清除分泌物
  3. C整夜每 10 分钟进行一次深部口咽吸引
  4. D调整体位，考虑使用已开具的抗分泌药物，并支持家属
9.内外科护理：心血管与呼吸中等

Why must inspired air be humidified for a patient with a tracheostomy?

  1. AHumidification prevents the cuff from deflating
  2. BHumidified air contains more oxygen than dry air at the same flow
  3. CDry air is needed to stop secretions forming in the trachea
  4. DThe nose and upper airway, which warm and moisten air, are bypassed
10.内外科护理：心血管与呼吸困难

A 25-year-old non-smoker has wheeze and cough that come and go, worse at night and after exercise. Spirometry improves markedly after a bronchodilator. Which diagnosis is most likely?

  1. AAsthma
  2. BHeart failure
  3. CIdiopathic pulmonary fibrosis
  4. DCOPD
11.内外科护理：神经、内分泌与肾脏中等

Which complication is a particular risk in nephrotic syndrome?

  1. ABleeding from low platelets
  2. BHypoglycaemia
  3. CLow cholesterol
  4. DVenous thrombosis
12.内外科护理：神经、内分泌与肾脏困难

血液透析期间，一名患者血压降至 80/50 mmHg，感到头晕恶心。最恰当的首要护理措施是什么？

  1. A让患者平躺，减少超滤，并寻求帮助
  2. B让患者坐直，并鼓励短距离行走
  3. C提高超滤速度，使透析更早结束
  4. D立即给予患者平时的降压药剂量
13.内外科护理：消化、围手术期与肿瘤中等

什么是肿瘤溶解综合征？

  1. A癌细胞迅速分解引起的代谢急症
  2. B对化疗输注的过敏反应
  3. C最近接受放疗区域的皮肤反应
  4. D压迫神经的缓慢生长的肿瘤
14.内外科护理：消化、围手术期与肿瘤困难

After surgery, a patient keeps asking for analgesia before it is due, watches the clock and rates pain 8/10. What is the most appropriate interpretation?

  1. APain may be undertreated; reassess and ask for a review of the plan
  2. BThe patient is addicted and should have analgesia withheld
  3. CThe patient needs only distraction and no change in drugs
  4. DThe patient is exaggerating, so the pain scores should be ignored for now

3溶液

1.优先排序与委派

答案: A · A parent of a 6-week-old with a temperature of 38.3 °C

为什么是这个答案

A fever in an infant under about 3 months old needs urgent assessment, because serious bacterial infection is more likely and signs can be subtle. The other calls are routine.

答案

A · A parent of a 6-week-old with a temperature of 38.3 °C
2.优先排序与委派

答案: A · Activate the rapid response team

为什么是这个答案

Nurses can call the rapid response team directly when a patient is deteriorating. The nurse also informs the charge nurse and follows the chain of command about the provider’s lack of response.

答案

A · Activate the rapid response team
3.感染控制与患者安全

答案: C · Standard precautions

为什么是这个答案

Botulism is caused by a toxin and does not spread from person to person, so standard precautions are used. Suspected cases are reported to public health at once.

答案

C · Standard precautions
4.感染控制与患者安全

答案: D · Three negative sputum smears, clinical improvement and continued therapy

为什么是这个答案

Airborne precautions usually continue until the patient is on effective therapy, is improving clinically and has three negative sputum smears for acid-fast bacilli, according to policy.

答案

D · Three negative sputum smears, clinical improvement and continued therapy
5.实验室检查值与电解质

答案: A · 脱水

为什么是这个答案

当身体缺水时，肾脏重吸收更多尿素，因此 BUN 的升高与肌酐不成比例（BUN 与肌酐之比高于 20:1）。肝衰竭和低蛋白饮食会使 BUN 降低。核对依据: BUN (Blood Urea Nitrogen) · MedlinePlus (NIH) (2024)

答案

A · 脱水
6.实验室检查值与电解质

答案: B · 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

B · Cushing syndrome
7.临床护理

答案: B · Genital fungal infections

为什么是这个答案

SGLT2 inhibitors cause glycosuria, which increases the risk of genital thrush and urinary infections. They can also rarely cause DKA with only modestly raised glucose.

答案

B · Genital fungal infections
8.临床护理

答案: D · 调整体位，考虑使用已开具的抗分泌药物，并支持家属

为什么是这个答案

"临终喉鸣"通过调整体位、口腔护理，有时使用减少分泌物的药物来处理。向家属解释可以减轻他们的痛苦。

答案

D · 调整体位，考虑使用已开具的抗分泌药物，并支持家属
9.内外科护理：心血管与呼吸

答案: D · The nose and upper airway, which warm and moisten air, are bypassed

为什么是这个答案

The tracheostomy bypasses the nose, mouth and pharynx, which warm, filter and humidify air. Without humidification, secretions become thick and can block the tube. Heat and moisture exchangers, humidified oxygen and nebulised saline are used.

答案

D · The nose and upper airway, which warm and moisten air, are bypassed
10.内外科护理：心血管与呼吸

答案: A · Asthma

为什么是这个答案

Asthma typically causes variable symptoms with reversible airflow obstruction. COPD usually affects older people with a smoking history and causes persistent, poorly reversible obstruction. Fibrosis gives a restrictive pattern.

答案

A · Asthma
11.内外科护理：神经、内分泌与肾脏

答案: D · Venous thrombosis

为什么是这个答案

In nephrotic syndrome, anticoagulant proteins such as antithrombin are lost, and clotting factors made by the liver rise, so venous thrombosis is more likely. Infection and high cholesterol are other complications.

答案

D · Venous thrombosis
12.内外科护理：神经、内分泌与肾脏

答案: A · 让患者平躺，减少超滤，并寻求帮助

为什么是这个答案

透析中低血压很常见。调整体位、减少或暂停超滤，并按方案给予少量生理盐水推注，通常可恢复血压。对易发生低血压的患者，降压药常按医嘱在透析前暂停。

答案

A · 让患者平躺，减少超滤，并寻求帮助
13.内外科护理：消化、围手术期与肿瘤

答案: A · 癌细胞迅速分解引起的代谢急症

为什么是这个答案

肿瘤细胞迅速死亡（通常在急性白血病或高级别淋巴瘤等快速生长的癌症开始治疗后）会释放钾、磷酸盐和核酸（转化为尿酸）。这可引起 AKI 和心律失常。

答案

A · 癌细胞迅速分解引起的代谢急症
14.内外科护理：消化、围手术期与肿瘤

答案: A · Pain may be undertreated; reassess and ask for a review of the plan

为什么是这个答案

Clock-watching often reflects inadequate analgesia. The nurse reassesses pain and function, considers multimodal options, and asks the prescriber to review the plan rather than labelling the patient.

答案

A · Pain may be undertreated; reassess and ask for a review of the plan

本内容为独立练习材料。ExamProblems 与该考试的主办机构没有隶属关系，也未获其认可，考试名称仅用于描述内容。 NCLEX®, NCLEX-RN® and NCLEX-PN® 是 the National Council of State Boards of Nursing, Inc. (NCSBN) 的商标，该机构与 ExamProblems 无关，不为其背书，也不保证其准确性。

ExamProblems · examproblems.com/courses/nclex-style-prioritization-and-delegation