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’s chest tube becomes disconnected from the drainage system. What should the nurse do first?

  1. ARemove the tube and cover the site
  2. BWait for the provider to arrive before doing anything else
  3. CClamp the tube for the rest of the shift
  4. DPlace the end of the tube in a bottle of sterile water
2.优先排序与委派困难

A patient has a new spinal cord injury at C4. Which assessment is the priority?

  1. ASkin over the sacrum and heels
  2. BBowel sounds in all four abdominal quadrants
  3. CBreathing effort and ability to cough
  4. DAbility to feed themselves
3.感染控制与患者安全中等

A family member tells the nurse, “My father is not himself. Something is wrong.” The hospital has a family-activated rapid response system. What is correct?

  1. AThe family should call emergency services from outside the hospital
  2. BThe family can call the rapid response team if they are worried and staff have not responded
  3. COnly doctors may call the rapid response team
  4. DThe family must wait for the next scheduled ward round to raise the concern with a doctor
4.感染控制与患者安全困难

一名患者伤口曾感染 MRSA，现在需要换药。哪种个人防护装备是恰当的？

  1. A仅戴 N95 呼吸器，因为 MRSA 是耐药菌
  2. B隔离衣和手套，若可能有飞溅则加戴护目装备和口罩
  3. C不用个人防护装备，只要事后清洁双手即可
  4. D仅戴无菌手套，不穿隔离衣或其他防护
5.实验室检查值与电解质中等

A patient with chronic kidney disease receives an erythropoiesis-stimulating agent such as epoetin alfa. Which assessments are most important?

  1. ASerum amylase and lipase
  2. BSerum glucose and ketones
  3. CHemoglobin and blood pressure
  4. DLiver enzymes and bilirubin
6.实验室检查值与电解质困难

A patient on high-dose dexamethasone has a white cell count of 15 × 10³/µL, mostly mature neutrophils with no bands. They have no fever and no signs of infection. What is the most likely explanation?

  1. AA laboratory error, because steroids always lower the white count
  2. BCertain sepsis that needs antibiotics started without delay
  3. CA steroid effect that moves neutrophils into the circulating blood
  4. DA new leukemia that is confirmed by this result alone
7.临床护理中等

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

  1. AHair loss
  2. BSevere weight gain and fluid retention
  3. CBradycardia
  4. DGenital fungal infections
8.临床护理困难

Soon after starting chemotherapy for a high-grade lymphoma, a patient has rising potassium, phosphate and uric acid with falling urine output. What is the most likely cause?

  1. ASyndrome of inappropriate ADH secretion
  2. BAdrenal insufficiency
  3. CTumour lysis syndrome
  4. DRefeeding syndrome
9.内外科护理：心血管与呼吸中等

How should a patient with asthma record their peak flow at home?

  1. ATake one gentle blow once a week, at any time of day
  2. BTake the best of three blows, ideally morning and evening
  3. CBlow only during an asthma attack, never when well
  4. DTake the average of ten blows after exercise
10.内外科护理：心血管与呼吸困难

一名肺炎患者使用经鼻高流量氧疗，流量 50 L/min，FiO₂ 0.6，SpO₂ 90%，呼吸频率 34 次/分，并使用辅助呼吸肌。最恰当的措施是什么？

  1. A让患者平躺，使呼吸肌得以休息
  2. B改为 4 L/min 鼻导管，以减轻鼻腔干燥
  3. C继续同样的支持，四小时后复查
  4. D紧急上报重症监护，评估呼吸支持
11.内外科护理：神经、内分泌与肾脏中等

A patient with Conn's syndrome starts spironolactone. Which blood test should the nurse watch most closely?

  1. AAmylase
  2. BCalcium
  3. CPotassium
  4. DGlucose
12.内外科护理：神经、内分泌与肾脏困难

一名腹膜透析患者发现引流出的液体比灌入的少。他们已四天没有排便，流出液清亮。最可能的原因是什么？

  1. A便秘阻碍了流出
  2. B细菌性腹膜炎
  3. C透析液温度过低
  4. D正常吸收，无需处理
13.内外科护理：消化、围手术期与肿瘤中等

Which nursing intervention best reduces preoperative anxiety?

  1. AAvoiding talking about the operation at all
  2. BExplaining what will happen and answering questions
  3. CTelling the patient that there is nothing to worry about
  4. DKeeping family members away until after surgery
14.内外科护理：消化、围手术期与肿瘤困难

A nurse teaches a patient with a new ileostomy. Which statement shows a need for further teaching?

  1. A"I'll watch for dizziness and dark urine."
  2. B"I'll drink less so my bag fills more slowly."
  3. C"I'll chew my food well to avoid blockages."
  4. D"I'll report if my output becomes very watery and high."

3溶液

1.优先排序与委派

答案: D · Place the end of the tube in a bottle of sterile water

为什么是这个答案

Putting the tube end in sterile water creates a temporary water seal until a new drainage system is connected. Long clamping can cause a tension pneumothorax, and the nurse does not remove the tube.

答案

D · Place the end of the tube in a bottle of sterile water
2.优先排序与委派

答案: C · Breathing effort and ability to cough

为什么是这个答案

Injuries at C3–C5 can affect the phrenic nerve and diaphragm, so breathing may fail. Respiratory function is monitored closely, and the patient may need ventilatory support.

答案

C · Breathing effort and ability to cough
3.感染控制与患者安全

答案: B · The family can call the rapid response team if they are worried and staff have not responded

为什么是这个答案

Family-activated rapid response systems allow patients and families to call for help directly when they notice a worrying change. The nurse should also take the concern seriously and assess the patient.

答案

B · The family can call the rapid response team if they are worried and staff have not responded
4.感染控制与患者安全

答案: B · 隔离衣和手套，若可能有飞溅则加戴护目装备和口罩

为什么是这个答案

MRSA 通过接触传播，因此应穿隔离衣、戴手套。标准预防要求在可能有伤口渗液飞溅时加用眼部和面部防护。伤口 MRSA 不需要呼吸器。

答案

B · 隔离衣和手套，若可能有飞溅则加戴护目装备和口罩
5.实验室检查值与电解质

答案: C · Hemoglobin and blood pressure

为什么是这个答案

Epoetin stimulates red cell production. Hemoglobin is monitored, because raising it too high increases the risk of hypertension, stroke and thrombosis. Blood pressure is monitored, and iron stores are checked, since iron is needed for a good response.核对依据: Erythropoietin Stimulating Agents · StatPearls (NCBI Bookshelf) (2024)

答案

C · Hemoglobin and blood pressure
6.实验室检查值与电解质

答案: C · A steroid effect that moves neutrophils into the circulating blood

为什么是这个答案

Corticosteroids raise the neutrophil count by releasing marginated neutrophils and slowing their exit from the blood, usually without a left shift. The nurse still assesses carefully, because steroids can also hide the usual signs of infection.

答案

C · A steroid effect that moves neutrophils into the circulating blood
7.临床护理

答案: D · 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

D · Genital fungal infections
8.临床护理

答案: C · Tumour lysis syndrome

为什么是这个答案

Rapid tumour cell death releases potassium, phosphate and nucleic acids (forming uric acid), which can cause AKI and arrhythmias. Prevention includes IV hydration and drugs to lower uric acid.

答案

C · Tumour lysis syndrome
9.内外科护理：心血管与呼吸

答案: B · Take the best of three blows, ideally morning and evening

为什么是这个答案

The patient stands or sits upright, takes a full breath and blows as hard and fast as possible, three times, recording the best. Regular readings show variability and guide the action plan, which uses the patient's own best value as the reference.

答案

B · Take the best of three blows, ideally morning and evening
10.内外科护理：心血管与呼吸

答案: D · 紧急上报重症监护，评估呼吸支持

为什么是这个答案

尽管使用高流量氧疗，仍有高氧需求、呼吸急促和呼吸做功增加，提示呼吸衰竭加重。需要尽早重症监护评估，以升级为 CPAP、NIV 或插管。降低支持或等待会有发生呼吸骤停的风险。

答案

D · 紧急上报重症监护，评估呼吸支持
11.内外科护理：神经、内分泌与肾脏

答案: C · Potassium

为什么是这个答案

Spironolactone is an aldosterone antagonist. It retains potassium, so hyperkalaemia can develop, especially with kidney disease or ACE inhibitors. Breast enlargement is another known side effect.

答案

C · Potassium
12.内外科护理：神经、内分泌与肾脏

答案: A · 便秘阻碍了流出

为什么是这个答案

流出不畅常由便秘、导管扭曲或导管移位引起。改变体位、检查夹子和管路以及治疗便秘通常有帮助；应上报。如果持续存在，需做影像学检查导管位置。流出液清亮使腹膜炎的可能性降低。

答案

A · 便秘阻碍了流出
13.内外科护理：消化、围手术期与肿瘤

答案: B · Explaining what will happen and answering questions

为什么是这个答案

Clear information about what to expect, including pain control and recovery, reduces anxiety and can improve recovery. False reassurance does not address the patient's concerns.

答案

B · Explaining what will happen and answering questions
14.内外科护理：消化、围手术期与肿瘤

答案: B · "I'll drink less so my bag fills more slowly."

为什么是这个答案

Restricting fluids increases dehydration risk with an ileostomy. Patients drink enough, add salt as advised, chew well and report high output or signs of dehydration.

答案

B · "I'll drink less so my bag fills more slowly."

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