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

一名护士要求护理助理使用机械升降机。助理说他们从未接受过使用它的培训。如果护士坚持，将违反委派的哪项正确原则？

  1. A正确的指示与沟通
  2. B正确的人员
  3. C正确的任务
  4. D正确的监督与评价
2.优先排序与委派困难

A provider asks a nurse to perform a procedure that is outside the nurse’s scope of practice. What should the nurse do?

  1. ADo it, because the provider gave the instruction
  2. BAsk a nursing assistant to do it instead
  3. CDecline, explain why and suggest who can safely do it
  4. DDo it just this once and promise the provider not to do it again
3.感染控制与患者安全中等

护士何时可以使用灭火器灭火？

  1. A只要有烟就可以，即使出口被堵住
  2. B绝不可以；只有消防员才能使用灭火器
  3. C仅当火势较小、已拉响警报且出口畅通时
  4. D总是可以，甚至在拉响警报之前，以节省时间
4.感染控制与患者安全困难

A handwritten order is hard to read, and the nurse is not sure of the drug name. What should the nurse do?

  1. AChoose the drug that seems most likely from the diagnosis
  2. BHold the drug until the next day without telling anyone
  3. CContact the prescriber to clarify before giving anything
  4. DAsk a colleague to guess what it says
5.实验室检查值与电解质中等

A patient taking spironolactone asks about using a salt substitute. What should the nurse explain?

  1. ASalt substitutes are safe because they contain only sodium chloride
  2. BSalt substitutes are fine as long as the patient drinks more water
  3. CSalt substitutes protect against the potassium loss caused by this drug
  4. DMost salt substitutes contain potassium and can raise the level too high
6.实验室检查值与电解质困难

一名慢性低钠血症（钠 118 mEq/L）患者正在接受治疗。为什么必须缓慢提高钠？

  1. A它可引起渗透性脱髓鞘，一种严重的脑损伤
  2. B缓慢纠正只是为了降低医院成本
  3. C快速纠正会导致低钾血症，这是唯一的风险
  4. D快速纠正会使钠再次进一步下降
7.临床护理中等

A patient without diabetes is started on high-dose prednisolone. Why might capillary blood glucose be monitored?

  1. ASteroids make glucose meters inaccurate
  2. BSteroids always cause hypoglycaemia
  3. CSteroids can raise the blood glucose
  4. DSteroids destroy the pancreas
8.临床护理困难

Which type of drug is commonly used to treat neuropathic pain?

  1. AProton pump inhibitors such as omeprazole
  2. BAntibiotics such as amoxicillin, given as a long course
  3. CSome anticonvulsants or antidepressants, such as gabapentin
  4. DAntihistamines such as cetirizine
9.内外科护理：心血管与呼吸中等

How does digoxin help a patient with atrial fibrillation and heart failure?

  1. AIt speeds conduction through the AV node to the ventricles
  2. BIt dissolves clots that have formed in the left atrium
  3. CIt lowers potassium to stabilise the heart
  4. DIt slows AV node conduction and increases contractility
10.内外科护理：心血管与呼吸困难

A nurse phones the doctor about a patient with pneumonia whose observations are worsening. Using SBAR, which statement is the clearest "recommendation"?

  1. A"His heart rate is 124/min, his BP is 88/50 mmHg and he is confused."
  2. B"He is 72 and was admitted yesterday with community-acquired pneumonia."
  3. C"I am calling about the patient in bed 6."
  4. D"I think he may have sepsis; please review him within 30 minutes."
11.内外科护理：神经、内分泌与肾脏中等

A patient taking warfarin is diagnosed with an intracerebral haemorrhage. What is the priority treatment?

  1. ADoubling the warfarin dose to stabilise the INR
  2. BStarting aspirin to prevent further clots
  3. CUrgent reversal of the anticoagulant effect
  4. DIV thrombolysis within 4.5 hours
12.内外科护理：神经、内分泌与肾脏困难

A haemodialysis patient missed their last two sessions. They are breathless, with crackles, and the potassium is 6.9 mmol/L. What is the priority?

  1. AOral potassium supplements and rest
  2. BA routine dialysis session at the next planned slot
  3. CLarge IV fluid boluses to improve the circulation
  4. DUrgent dialysis, with cardiac monitoring meanwhile
13.内外科护理：消化、围手术期与肿瘤中等

Which advice is appropriate for a patient with a very low platelet count?

  1. ATake aspirin regularly for headaches
  2. BUse a soft toothbrush and an electric razor
  3. CFloss hard every day to prevent gum disease
  4. DUse a razor blade for shaving every day
14.内外科护理：消化、围手术期与肿瘤困难

A patient with facial burns from a house fire was talking normally on arrival. Two hours later, the voice is hoarse and there is stridor. What should the nurse do?

  1. AEncourage the patient to rest the voice and reassess tomorrow
  2. BGive a warm drink to soothe the throat
  3. CCall for urgent anaesthetic help, as the airway is swelling
  4. DLay the patient flat to help them sleep

3溶液

1.优先排序与委派

答案: B · 正确的人员

为什么是这个答案

正确的人员是指被委派者接受过该任务的培训并有能力完成。使用升降机通常是可委派的任务，但不能委派给没有接受过培训的人。护士应安排培训或在协助下自己完成任务。

答案

B · 正确的人员
2.优先排序与委派

答案: C · Decline, explain why and suggest who can safely do it

为什么是这个答案

Nurses must work within their legal scope of practice, even when asked by a provider. The nurse declines, explains the reason and helps find a suitable professional.

答案

C · Decline, explain why and suggest who can safely do it
3.感染控制与患者安全

答案: C · 仅当火势较小、已拉响警报且出口畅通时

为什么是这个答案

在人员安全且已拉响警报之后，工作人员可以尝试扑灭局限的小火，并保证身后有退路。否则，应关闭门窗并疏散。

答案

C · 仅当火势较小、已拉响警报且出口畅通时
4.感染控制与患者安全

答案: C · Contact the prescriber to clarify before giving anything

为什么是这个答案

Illegible or unclear orders are clarified directly with the prescriber. The nurse never guesses, and a held dose is reported so treatment is not missed.

答案

C · Contact the prescriber to clarify before giving anything
5.实验室检查值与电解质

答案: D · Most salt substitutes contain potassium and can raise the level too high

为什么是这个答案

Spironolactone blocks aldosterone, so the kidneys keep potassium. Many salt substitutes are made of potassium chloride, and combining them with spironolactone can cause dangerous hyperkalemia, especially with kidney disease or ACE inhibitors.核对依据: Spironolactone · MedlinePlus (NIH) (2018); High potassium level · MedlinePlus (NIH) (2025)

答案

D · Most salt substitutes contain potassium and can raise the level too high
6.实验室检查值与电解质

答案: A · 它可引起渗透性脱髓鞘，一种严重的脑损伤

为什么是这个答案

当低钠血症缓慢形成时，脑细胞已适应。过快提高钠会使脑细胞皱缩，并可损害神经细胞的髓鞘（渗透性脱髓鞘）。许多指南将 24 小时内的升高限制在约 8–10 mEq/L。核对依据: Osmotic demyelination syndrome · MedlinePlus (NIH) (2026)

答案

A · 它可引起渗透性脱髓鞘，一种严重的脑损伤
7.临床护理

答案: C · Steroids can raise the blood glucose

为什么是这个答案

Glucocorticoids increase glucose production and insulin resistance, causing steroid-induced hyperglycaemia. Glucose monitoring identifies patients who need treatment.

答案

C · Steroids can raise the blood glucose
8.临床护理

答案: C · Some anticonvulsants or antidepressants, such as gabapentin

为什么是这个答案

Neuropathic pain responds poorly to standard analgesics. Drugs that modify nerve signalling, such as gabapentinoids and some antidepressants, are used, with doses increased gradually.

答案

C · Some anticonvulsants or antidepressants, such as gabapentin
9.内外科护理：心血管与呼吸

答案: D · It slows AV node conduction and increases contractility

为什么是这个答案

Digoxin inhibits the Na⁺/K⁺-ATPase, raising intracellular calcium and contractility, and increases vagal tone, slowing AV conduction and the ventricular rate. It controls symptoms but does not reduce stroke risk, so anticoagulation is still needed in AF.

答案

D · It slows AV node conduction and increases contractility
10.内外科护理：心血管与呼吸

答案: D · "I think he may have sepsis; please review him within 30 minutes."

为什么是这个答案

In SBAR, the recommendation states clearly what the nurse needs and how quickly, such as a review within a set time. The other statements belong to situation, background and assessment. Structured communication reduces delays in escalation.

答案

D · "I think he may have sepsis; please review him within 30 minutes."
11.内外科护理：神经、内分泌与肾脏

答案: C · Urgent reversal of the anticoagulant effect

为什么是这个答案

Anticoagulants make the haematoma expand. Warfarin is reversed urgently, typically with prothrombin complex concentrate and IV vitamin K. Thrombolysis and antiplatelets are contraindicated in a bleed.

答案

C · Urgent reversal of the anticoagulant effect
12.内外科护理：神经、内分泌与肾脏

答案: D · Urgent dialysis, with cardiac monitoring meanwhile

为什么是这个答案

Missing dialysis causes fluid overload and hyperkalaemia, both of which can be fatal. The patient needs cardiac monitoring, emergency treatment of the potassium and urgent dialysis to remove fluid and potassium.

答案

D · Urgent dialysis, with cardiac monitoring meanwhile
13.内外科护理：消化、围手术期与肿瘤

答案: B · Use a soft toothbrush and an electric razor

为什么是这个答案

With thrombocytopenia, the nurse reduces bleeding risk: soft toothbrush, electric razor, no NSAIDs or aspirin, avoiding IM injections and rectal procedures, and reporting bleeding, bruising or blood in urine or stool.

答案

B · Use a soft toothbrush and an electric razor
14.内外科护理：消化、围手术期与肿瘤

答案: C · Call for urgent anaesthetic help, as the airway is swelling

为什么是这个答案

Progressive hoarseness and stridor after a facial or inhalation burn mean the airway is narrowing. Early intubation by an experienced anaesthetist is needed before swelling makes it impossible. The patient is sat up and given oxygen.

答案

C · Call for urgent anaesthetic help, as the airway is swelling

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