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 taking lisinopril develops swelling of the lips and tongue. What should the nurse do first?

  1. AAssess the airway and call for urgent help
  2. BApply a cold pack and recheck in an hour
  3. CGive the next dose of lisinopril with water
  4. DTell the patient this is a common, harmless effect
2.优先排序与委派困难

A trauma patient has an open leg fracture, absent breath sounds on one side, a trachea shifted to the other side and a falling blood pressure. Which problem is the priority?

  1. AThe risk of wound infection
  2. BThe pain from the fracture
  3. CThe suspected tension pneumothorax
  4. DThe open fracture of the leg
3.感染控制与患者安全中等

护理采取空气传播预防的患者后，N95 呼吸器应在何时摘下？

  1. A离开房间并关上门之后
  2. B绝不摘下；整个班次都佩戴
  3. C在房间内、脱手套之前
  4. D刚进入房间后立即摘下
4.感染控制与患者安全困难

A patient rescued from a house fire has a headache and confusion, but the pulse oximeter reads 99%. Why might this reading be misleading?

  1. APulse oximeters always read falsely low after any kind of smoke exposure
  2. BThe reading is accurate, so carbon monoxide poisoning is ruled out
  3. CPulse oximetry cannot tell carbon monoxide-bound hemoglobin from oxygen-bound hemoglobin
  4. DConfusion and headache make pulse oximetry readings inaccurate in every patient
5.实验室检查值与电解质中等

A patient takes high-dose biotin supplements for hair and nails. Why should the nurse report this before blood tests?

  1. ABiotin lowers the hemoglobin by destroying the red cells
  2. BBiotin can distort some immunoassays, such as troponin or TSH
  3. CBiotin causes a true rise in blood glucose in all patients
  4. DBiotin makes the blood clot in the tube before testing
6.实验室检查值与电解质困难

Four results arrive at the same time. Which patient should the nurse see first?

  1. AINR 2.6 in a patient on warfarin for atrial fibrillation
  2. BWhite cell count 12.0 × 10³/µL on the first day after surgery
  3. CGlucose 48 mg/dL (2.7 mmol/L) in a patient who had insulin an hour ago
  4. DHemoglobin 10.4 g/dL (104 g/L) in a patient with stable chronic kidney disease
7.临床护理中等

A patient with sickle cell disease is admitted with a painful crisis. What is a key early nursing priority?

  1. ADelaying pain relief until a diagnosis is confirmed
  2. BRestricting oral fluids
  3. CGiving prompt, effective analgesia
  4. DApplying cold packs to the painful areas
8.临床护理困难

A nurse teaches a patient with hypertension about their medicines. Which statement shows a need for further teaching?

  1. A"I'll stop my tablets once my readings are normal."
  2. B"I'll get up slowly from sitting."
  3. C"I'll keep taking my tablets even if I feel well."
  4. D"I'll have my blood pressure checked regularly."
9.内外科护理：心血管与呼吸中等

A patient taking isosorbide mononitrate asks about sildenafil for erectile dysfunction. What is the main danger?

  1. ABleeding from the gums
  2. BSevere hypertension
  3. CSevere hypotension
  4. DA very high potassium level
10.内外科护理：心血管与呼吸困难

A patient with severe chronic kidney disease needs therapeutic anticoagulation for a DVT. Why might unfractionated heparin be chosen instead of a low-molecular-weight heparin?

  1. ALMWH cannot be given to anyone over 60
  2. BUnfractionated heparin has no bleeding risk at all
  3. CUnfractionated heparin is taken by mouth
  4. DLMWH is cleared by the kidneys and can accumulate
11.内外科护理：神经、内分泌与肾脏中等

Several hours after a carotid endarterectomy, which finding needs the most urgent action?

  1. AA small amount of dried blood on the dressing
  2. BA blood pressure slightly above the baseline
  3. CMild pain at the incision site
  4. DAn expanding neck swelling with noisy breathing
12.内外科护理：神经、内分泌与肾脏困难

A patient who has taken prednisolone daily for years is vomiting and cannot keep tablets down. What should the nurse do?

  1. AGive the tablets again after every vomit
  2. BGive the next dose with a glass of milk
  3. CEscalate urgently for steroid by injection
  4. DOmit the steroid until the vomiting stops
13.内外科护理：消化、围手术期与肿瘤中等

Which practice is correct when giving parenteral nutrition through a central line?

  1. ADisconnect and reconnect the line without cleaning the hub
  2. BLet the bag hang at room temperature for several days
  3. CGive other IV drugs through the same lumen to save time
  4. DUse a dedicated lumen and strict aseptic technique
14.内外科护理：消化、围手术期与肿瘤困难

A patient is splashed in the eye with an alkaline cleaning product. What is the first action?

  1. AAdd a few drops of vinegar to neutralise it
  2. BAsk the patient to rub the eye to clear it
  3. CCover the eye with a pad and wait for a doctor to examine it first
  4. DIrrigate the eye at once with large volumes of water or saline

3溶液

1.优先排序与委派

答案: A · Assess the airway and call for urgent help

为什么是这个答案

Angioedema is a rare but dangerous effect of ACE inhibitors. The airway comes first: the nurse assesses breathing, calls for urgent help and holds the drug.

答案

A · Assess the airway and call for urgent help
2.优先排序与委派

答案: C · The suspected tension pneumothorax

为什么是这个答案

A shifted trachea, absent breath sounds and hypotension suggest tension pneumothorax, which threatens breathing and circulation within minutes. The fracture is important, but it comes after the immediate life threat.

答案

C · The suspected tension pneumothorax
3.感染控制与患者安全

答案: A · 离开房间并关上门之后

为什么是这个答案

因为传染性颗粒仍留在房间的空气中，所以应在房门关闭后到房间外摘下呼吸器，随后进行手卫生。手套、护目装备和隔离衣应先脱下。

答案

A · 离开房间并关上门之后
4.感染控制与患者安全

答案: C · Pulse oximetry cannot tell carbon monoxide-bound hemoglobin from oxygen-bound hemoglobin

为什么是这个答案

Standard pulse oximeters read carboxyhemoglobin as oxyhemoglobin, so SpO2 can look normal in carbon monoxide poisoning. A blood carboxyhemoglobin level confirms it, and high-flow oxygen is given.

答案

C · Pulse oximetry cannot tell carbon monoxide-bound hemoglobin from oxygen-bound hemoglobin
5.实验室检查值与电解质

答案: B · Biotin can distort some immunoassays, such as troponin or TSH

为什么是这个答案

Many immunoassays use biotin-streptavidin binding, and high blood biotin levels can give falsely high or low results, for example a falsely low troponin or abnormal thyroid tests. The laboratory and prescriber should know about biotin use.核对依据: Troponin Test · MedlinePlus (NIH) (2023); Biotin Interference with Troponin Lab Tests - Assays Subject to Biotin Interference · U.S. FDA (2022)

答案

B · Biotin can distort some immunoassays, such as troponin or TSH
6.实验室检查值与电解质

答案: C · Glucose 48 mg/dL (2.7 mmol/L) in a patient who had insulin an hour ago

为什么是这个答案

Hypoglycemia after insulin can quickly cause seizures and loss of consciousness, so it is treated first. Mild anemia in CKD is expected, an INR of 2.6 is within the target range, and a slightly raised white count is common after surgery.核对依据: Blood Glucose Test · MedlinePlus (NIH) (2024); Prothrombin time (PT) · MedlinePlus (NIH) (2025)

答案

C · Glucose 48 mg/dL (2.7 mmol/L) in a patient who had insulin an hour ago
7.临床护理

答案: C · Giving prompt, effective analgesia

为什么是这个答案

A sickle cell crisis needs rapid analgesia, often opioids, within a short target time, plus hydration, oxygen if hypoxic, warmth and monitoring for complications. Cold can trigger more sickling.

答案

C · Giving prompt, effective analgesia
8.临床护理

答案: A · "I'll stop my tablets once my readings are normal."

为什么是这个答案

Hypertension usually needs long-term treatment; stopping because readings are normal often makes blood pressure rise again. Patients should discuss any changes with their prescriber.

答案

A · "I'll stop my tablets once my readings are normal."
9.内外科护理：心血管与呼吸

答案: C · Severe hypotension

为什么是这个答案

Phosphodiesterase-5 inhibitors such as sildenafil enhance the vasodilator effect of nitrates and can cause profound, life-threatening hypotension. The combination is contraindicated, and patients should tell emergency staff if they have taken one.

答案

C · Severe hypotension
10.内外科护理：心血管与呼吸

答案: D · LMWH is cleared by the kidneys and can accumulate

为什么是这个答案

Low-molecular-weight heparins are mainly renally excreted, so they accumulate in severe renal impairment and increase bleeding risk. Unfractionated heparin is cleared mainly by other routes, has a short half-life and can be monitored with aPTT and reversed with protamine.

答案

D · LMWH is cleared by the kidneys and can accumulate
11.内外科护理：神经、内分泌与肾脏

答案: D · An expanding neck swelling with noisy breathing

为什么是这个答案

A neck haematoma after carotid surgery can compress the airway quickly. It needs immediate senior help and may need the wound opened. Neurological checks for new stroke and cranial nerve damage are also part of routine care.

答案

D · An expanding neck swelling with noisy breathing
12.内外科护理：神经、内分泌与肾脏

答案: C · Escalate urgently for steroid by injection

为什么是这个答案

Patients on long-term steroids depend on them. If tablets cannot be absorbed, they can develop an adrenal crisis. Parenteral hydrocortisone is needed, following sick-day guidance.

答案

C · Escalate urgently for steroid by injection
13.内外科护理：消化、围手术期与肿瘤

答案: D · Use a dedicated lumen and strict aseptic technique

为什么是这个答案

PN is rich in nutrients that bacteria can use. A dedicated lumen, aseptic non-touch technique and hanging limits reduce catheter-related bloodstream infection.

答案

D · Use a dedicated lumen and strict aseptic technique
14.内外科护理：消化、围手术期与肿瘤

答案: D · Irrigate the eye at once with large volumes of water or saline

为什么是这个答案

Alkali burns can cause severe, deep eye damage. Immediate, prolonged irrigation, checking the pH, and urgent ophthalmology review are needed. Neutralising agents are not used.

答案

D · Irrigate the eye at once with large volumes of water or saline

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