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

When making patient assignments, what should the charge nurse consider first?

  1. AGiving each nurse patients in rooms next to each other
  2. BGiving the newest staff the most complex patients
  3. CLetting staff choose the patients they prefer
  4. DMatching each patient’s needs to staff competence
2.优先排序与委派困难

A patient taking an MAO inhibitor antidepressant is taught about diet. Which statement shows a need for further teaching?

  1. A“A sudden severe headache is a warning sign.”
  2. B“I will avoid tap beer and red wine.”
  3. C“I will check with the pharmacist before cold remedies.”
  4. D“I can still eat aged cheese and cured salami.”
3.感染控制与患者安全中等

A patient has received oral radioactive iodine therapy. Which precaution is usually taken?

  1. AEncourage pregnant visitors to sit close to the patient to give emotional support
  2. BLet the patient share a bathroom with other patients
  3. CLimit time close to the patient and handle body fluids per radiation policy
  4. DPlace the patient on droplet precautions with a surgical mask
4.感染控制与患者安全困难

在口服药发药过程中，一名患者要求稍后再服一片药。护士把药留在了床头柜上。主要的安全问题是什么？

  1. A药片放在空气中会很快溶解
  2. B药片可能褪色，之后难以辨认
  3. C护士无法确认患者是否服下，而且别人可能会拿走
  4. D如果患者清醒，就没有安全问题
5.实验室检查值与电解质中等

A trauma patient receives 2 L of IV crystalloid. The hemoglobin falls from 13.0 to 11.4 g/dL (130 to 114 g/L), and the vital signs are now stable. Which explanation is most likely?

  1. AA sudden failure of the bone marrow
  2. BA laboratory error in the first sample
  3. CIncreased red cell production
  4. DDilution of the blood by the IV fluid
6.实验室检查值与电解质困难

In the first 24 hours after a major burn, which laboratory pattern is most expected?

  1. AHigh potassium and high hematocrit
  2. BLow sodium and low hematocrit
  3. CHigh calcium and high albumin
  4. DLow potassium and low hematocrit
7.临床护理中等

What is the recommended first aid for a thermal burn?

  1. ABurst any blisters to release the fluid
  2. BApply ice directly to the burn until the pain stops completely
  3. CCool it under cool running water for about 20 minutes
  4. DSpread butter or oil over the burn
8.临床护理困难

A patient who speaks little English needs to give consent for a procedure. Their 14-year-old child offers to interpret. What is the best action?

  1. AArrange a professional interpreter
  2. BLet the child interpret to save time
  3. CAsk the patient to sign the form without explanation
  4. DUse gestures and proceed
9.内外科护理：心血管与呼吸中等

Which skin changes around the ankles are typical of chronic venous insufficiency?

  1. ABrown staining, swelling and dry, itchy skin
  2. BPale, shiny, hairless skin with weak pulses
  3. CA cold, white foot with no pulse
  4. DA sharply defined red patch with fever
10.内外科护理：心血管与呼吸困难

一名已知外周动脉疾病的患者突然出现足部冰冷、苍白、疼痛，没有脉搏，脚趾麻木。优先处理是什么？

  1. A立即作为急症上报；保持腿部水平，不加热
  2. B使用加压绷带以改善循环
  3. C鼓励行走以开放侧支循环
  4. D用枕头抬高腿，并用热水袋温暖足部
11.内外科护理：神经、内分泌与肾脏中等

Why might a patient bleed more from the needle sites straight after haemodialysis?

  1. ADialysis raises the blood pressure sharply for several hours
  2. BDialysis removes all the platelets from the blood
  3. CHeparin is often used to stop the circuit from clotting
  4. DThe fistula has been damaged and must be tied off
12.内外科护理：神经、内分泌与肾脏困难

A patient who had pituitary surgery has fatigue and feels cold. TSH is low, and free T4 is low. What is the most likely cause?

  1. APrimary hypothyroidism from thyroid failure
  2. BOver-replacement with levothyroxine
  3. CSecondary hypothyroidism
  4. DHyperthyroidism from Graves' disease
13.内外科护理：消化、围手术期与肿瘤中等

为什么教患者咳嗽时用枕头支托腹部伤口？

  1. A它可减轻疼痛和牵拉，使患者能有效咳嗽
  2. B它使咳嗽变弱，从而不使伤口受到风险
  3. C它加速皮肤边缘的愈合
  4. D它取代了规律镇痛的需要
14.内外科护理：消化、围手术期与肿瘤困难

Four patients are on a gastroenterology ward. Which should the nurse see first?

  1. AA patient with an ileostomy waiting to change the pouch
  2. BA patient with cirrhosis who is newly confused and drowsy
  3. CA patient with stable ulcerative colitis asking about diet
  4. DA patient with GORD who wants an antacid

3溶液

1.优先排序与委派

答案: D · Matching each patient’s needs to staff competence

为什么是这个答案

Assignments are based mainly on patient acuity and needs and on each staff member’s skills and scope. Geography and continuity of care help, but they come after safety.

答案

D · Matching each patient’s needs to staff competence
2.优先排序与委派

答案: D · “I can still eat aged cheese and cured salami.”

为什么是这个答案

MAO inhibitors with tyramine-rich foods, such as aged cheese and cured meats, can cause a hypertensive crisis. Patients avoid these foods, check medicines with a pharmacist and report a severe headache.

答案

D · “I can still eat aged cheese and cured salami.”
3.感染控制与患者安全

答案: C · Limit time close to the patient and handle body fluids per radiation policy

为什么是这个答案

Radioactive iodine is excreted in urine, sweat and saliva, so the patient is usually in a private room with their own bathroom. Staff limit time near them, use distance and follow policy for body fluids and waste.

答案

C · Limit time close to the patient and handle body fluids per radiation policy
4.感染控制与患者安全

答案: C · 护士无法确认患者是否服下，而且别人可能会拿走

为什么是这个答案

除非有商定的自行服药计划，否则不应把药留在床边。护士必须看到患者服药才能正确记录，无人看管的药片可能被其他患者拿走或遗失。

答案

C · 护士无法确认患者是否服下，而且别人可能会拿走
5.实验室检查值与电解质

答案: D · Dilution of the blood by the IV fluid

为什么是这个答案

IV fluids dilute the blood, so the hemoglobin falls even without further bleeding. Ongoing bleeding must still be considered, so vital signs, wounds and repeat hemoglobin values are monitored.

答案

D · Dilution of the blood by the IV fluid
6.实验室检查值与电解质

答案: A · High potassium and high hematocrit

为什么是这个答案

Early after a burn, damaged cells release potassium, and plasma shifts into the tissues, which concentrates the blood and raises the hematocrit. Later, as fluid returns and the kidneys excrete potassium, hypokalemia can develop.核对依据: High potassium level · MedlinePlus (NIH) (2025)

答案

A · High potassium and high hematocrit
7.临床护理

答案: C · Cool it under cool running water for about 20 minutes

为什么是这个答案

Cooling with running water for around 20 minutes limits tissue damage and pain. Ice can cause further injury, and the patient should be kept warm while the burn is cooled.

答案

C · Cool it under cool running water for about 20 minutes
8.临床护理

答案: A · Arrange a professional interpreter

为什么是这个答案

Professional interpreters provide accurate, impartial translation and protect confidentiality. Children and family members should not be used for important clinical discussions such as consent.

答案

A · Arrange a professional interpreter
9.内外科护理：心血管与呼吸

答案: A · Brown staining, swelling and dry, itchy skin

为什么是这个答案

High venous pressure causes oedema and leakage of red cells, depositing haemosiderin (brown staining), with venous eczema and lipodermatosclerosis. Pale, shiny, hairless skin suggests arterial disease. Venous ulcers often form above the medial malleolus.

答案

A · Brown staining, swelling and dry, itchy skin
10.内外科护理：心血管与呼吸

答案: A · 立即作为急症上报；保持腿部水平，不加热

为什么是这个答案

疼痛（pain）、苍白（pallor）、无脉（pulselessness）、感觉异常（paraesthesia）、麻痹（paralysis）和肢体冰冷（perishingly cold）提示急性肢体缺血，通常由栓子或血栓引起。需要在数小时内重建血运才能保住肢体。加热会增加代谢需求并可造成烫伤，抬高会减少动脉血流，加压则有害。

答案

A · 立即作为急症上报；保持腿部水平，不加热
11.内外科护理：神经、内分泌与肾脏

答案: C · Heparin is often used to stop the circuit from clotting

为什么是这个答案

Heparin is commonly used during haemodialysis to prevent clotting in the circuit. Its effect can cause prolonged bleeding from puncture sites, so procedures such as IM injections may be timed with care.

答案

C · Heparin is often used to stop the circuit from clotting
12.内外科护理：神经、内分泌与肾脏

答案: C · Secondary hypothyroidism

为什么是这个答案

When the pituitary cannot make enough TSH, the thyroid is not stimulated, so both TSH and free T4 are low. In primary thyroid failure, TSH is high. In secondary hypothyroidism, free T4, not TSH, is used to guide the dose.

答案

C · Secondary hypothyroidism
13.内外科护理：消化、围手术期与肿瘤

答案: A · 它可减轻疼痛和牵拉，使患者能有效咳嗽

为什么是这个答案

支托切口可减轻疼痛和对伤口的压力，使患者能够深呼吸和有效咳嗽，以清除分泌物并预防胸部感染。同时还需要充分的镇痛。

答案

A · 它可减轻疼痛和牵拉，使患者能有效咳嗽
14.内外科护理：消化、围手术期与肿瘤

答案: B · A patient with cirrhosis who is newly confused and drowsy

为什么是这个答案

New confusion and drowsiness in cirrhosis may be hepatic encephalopathy with a precipitant such as bleeding or infection, and the airway may be at risk. The others are stable.

答案

B · A patient with cirrhosis who is newly confused and drowsy

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