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

交班后，护士应首先看哪位患者？

  1. A一名服用利尿剂的患者，自 08:00 起已排尿 400 mL
  2. B一名想在访客到来之前得到帮助淋浴的患者
  3. C一名骨关节炎患者，诉说每天早晨僵硬
  4. D一名新打石膏的患者，说足部发麻，脚趾发凉
2.优先排序与委派困难

After a head injury, a patient has clear fluid dripping from the nose. Which action should the nurse avoid?

  1. APlacing a loose gauze under the nose
  2. BChecking the fluid for glucose or a halo sign on gauze
  3. CInforming the provider about the drainage
  4. DInserting a tube or suction catheter through the nose
3.感染控制与患者安全中等

Which type of white blood cell is most often raised in viral infections?

  1. ALymphocytes
  2. BBasophils
  3. CNeutrophils
  4. DEosinophils
4.感染控制与患者安全困难

一名干细胞移植后严重免疫抑制的患者住在保护性环境中。下列哪件物品不应带入房间？

  1. A一张已擦拭干净的相框全家福
  2. B一台干净、已消毒的平板电脑
  3. C患者自己的干净衣物
  4. D鲜花或盆栽植物
5.实验室检查值与电解质中等

Which finding during a transfusion suggests transfusion-associated circulatory overload (TACO)?

  1. AHives and itching without other signs
  2. BBack pain with dark red urine output
  3. CA low temperature and slow heart rate
  4. DCrackles, hypertension and a raised BNP
6.实验室检查值与电解质困难

A patient on clozapine for 2 years has been stable. Which statement shows a need for further teaching?

  1. A"I'll tell other doctors that I take clozapine"
  2. B"I'll report a sore throat or fever at once"
  3. C"I can stop my blood tests since I feel well"
  4. D"I'll keep all my scheduled blood test visits"
7.临床护理中等

A patient on insulin reports nightmares, night sweats and morning headaches. What should be suspected?

  1. AHyperthyroidism
  2. BNight-time hypoglycaemia
  3. CRaised intracranial pressure
  4. DA urinary tract infection
8.临床护理困难

Three days after bowel surgery, a patient has a distended abdomen, vomiting and absent bowel sounds, without colicky pain. What is most likely?

  1. AAcute cholecystitis
  2. BNormal recovery after surgery
  3. CA urinary tract infection
  4. DParalytic ileus
9.内外科护理：心血管与呼吸中等

A patient on furosemide has a serum potassium of 3.0 mmol/L (3.0 mEq/L). Which symptoms may this cause?

  1. AMuscle weakness, cramps and an irregular pulse
  2. BSevere headache and a stiff neck
  3. CTingling around the lips and painful spasm of the hands
  4. DFacial flushing, fever and a skin rash
10.内外科护理：心血管与呼吸困难

一名哮喘患者的峰流速为其最佳值的 40%，呼吸频率 28 次/分，不能说完整句子。SpO₂ 94%。该次发作应如何分级？

  1. A濒死性哮喘
  2. B中度哮喘加重
  3. C危及生命的哮喘
  4. D急性重度哮喘
11.内外科护理：神经、内分泌与肾脏中等

Why is once-daily prednisolone usually taken in the morning with food?

  1. ATo match the natural cortisol rhythm and protect the stomach
  2. BBecause it causes drowsiness and is safer to take during the day
  3. CBecause food doubles the strength of the dose
  4. DBecause it cannot be absorbed at night
12.内外科护理：神经、内分泌与肾脏困难

An older man was found on the floor after lying there for many hours. His urine is dark brown, and his creatine kinase is very high. What is the main kidney risk and the key treatment?

  1. AHypothermia, treated with a fluid restriction
  2. BAKI from rhabdomyolysis, treated with generous IV fluids
  3. CA kidney stone, treated with strong pain relief
  4. DA urinary infection, treated with oral antibiotics only
13.内外科护理：消化、围手术期与肿瘤中等

为什么肝硬化患者的出血风险增加？

  1. A肝硬化使血小板计数升高，从而使血小板变弱
  2. B肝硬化时的高动脉血压使血管破裂
  3. C瘢痕化的肝脏将肝素等抗凝物质释放到血液中
  4. D凝血因子减少、血小板低，以及门静脉高压引起的曲张静脉
14.内外科护理：消化、围手术期与肿瘤困难

A patient arrives in the anaesthetic room without an identity band. What should the nurse do?

  1. AStop and confirm identity, then apply a band
  2. BUse the spare identity band from the front of the patient's notes folder
  3. CProceed and add a band once in recovery
  4. DProceed because the patient can say their name

3溶液

1.优先排序与委派

答案: D · 一名新打石膏的患者，说足部发麻，脚趾发凉

为什么是这个答案

石膏下麻木和脚趾发凉提示循环受损，可能是骨筋膜室综合征，数小时内即可造成永久性损害。其他发现是预期的或常规的。

答案

D · 一名新打石膏的患者，说足部发麻，脚趾发凉
2.优先排序与委派

答案: D · Inserting a tube or suction catheter through the nose

为什么是这个答案

Clear nasal drainage after a head injury can be cerebrospinal fluid from a basal skull fracture. Nasal tubes could enter the brain and introduce infection, so they are avoided.

答案

D · Inserting a tube or suction catheter through the nose
3.感染控制与患者安全

答案: A · Lymphocytes

为什么是这个答案

Lymphocytes increase in many viral infections. Neutrophils rise mainly with bacterial infections, and eosinophils with allergies and parasites.

答案

A · Lymphocytes
4.感染控制与患者安全

答案: D · 鲜花或盆栽植物

为什么是这个答案

鲜花和植物可携带曲霉菌（Aspergillus）等霉菌以及水源性细菌，可在严重免疫功能低下的患者中引起严重感染。干净、可擦拭的个人物品通常是允许的。

答案

D · 鲜花或盆栽植物
5.实验室检查值与电解质

答案: D · Crackles, hypertension and a raised BNP

为什么是这个答案

TACO is fluid overload, often in older adults or those with heart or kidney disease. It causes dyspnea, crackles, hypertension, distended neck veins and a raised BNP. The transfusion is stopped, the patient is sat up and diuretics may be prescribed.

答案

D · Crackles, hypertension and a raised BNP
6.实验室检查值与电解质

答案: C · "I can stop my blood tests since I feel well"

为什么是这个答案

Clozapine requires ongoing ANC monitoring according to the schedule, because severe neutropenia can occur without warning. The patient must keep blood test appointments and report signs of infection at once.

答案

C · "I can stop my blood tests since I feel well"
7.临床护理

答案: B · Night-time hypoglycaemia

为什么是这个答案

Nocturnal hypoglycaemia can cause sweating, restless sleep, nightmares and morning headache. Checking glucose overnight and reviewing insulin doses can confirm and correct it.

答案

B · Night-time hypoglycaemia
8.临床护理

答案: D · Paralytic ileus

为什么是这个答案

Paralytic ileus is a temporary loss of gut movement, common after abdominal surgery. Bowel sounds are absent, unlike mechanical obstruction where they are often high-pitched. Management includes nil by mouth, NG decompression, fluids and correcting electrolytes.

答案

D · Paralytic ileus
9.内外科护理：心血管与呼吸

答案: A · Muscle weakness, cramps and an irregular pulse

为什么是这个答案

The adult reference range is about 3.5–5.0 mmol/L, so 3.0 mmol/L is low. Hypokalaemia causes weakness, cramps, constipation and arrhythmias, with flattened T waves and U waves on the ECG. Tingling lips and hand spasm suggest low calcium.

答案

A · Muscle weakness, cramps and an irregular pulse
10.内外科护理：心血管与呼吸

答案: D · 急性重度哮喘

为什么是这个答案

在常用指南（如 BTS/SIGN）中，峰流速为最佳值的 33–50%、呼吸频率 25 次/分或以上、心率 110 次/分或以上，或不能说完整句子，提示急性重度哮喘。危及生命的特征包括峰流速低于 33%、SpO₂ 低于 92%、“沉默肺”、发绀、衰竭或意识混乱；濒死性哮喘是指 PaCO₂ 升高或需要通气。

答案

D · 急性重度哮喘
11.内外科护理：神经、内分泌与肾脏

答案: A · To match the natural cortisol rhythm and protect the stomach

为什么是这个答案

Morning dosing mimics the normal early-morning cortisol peak, causes less adrenal suppression and less sleep disturbance. Taking it with food reduces gastric irritation.

答案

A · To match the natural cortisol rhythm and protect the stomach
12.内外科护理：神经、内分泌与肾脏

答案: B · AKI from rhabdomyolysis, treated with generous IV fluids

为什么是这个答案

Prolonged pressure damages muscle (rhabdomyolysis), releasing myoglobin, which is toxic to the tubules, as well as potassium. Early, generous IV fluids with close monitoring of urine output, potassium and creatinine help protect the kidneys.

答案

B · AKI from rhabdomyolysis, treated with generous IV fluids
13.内外科护理：消化、围手术期与肿瘤

答案: D · 凝血因子减少、血小板低，以及门静脉高压引起的曲张静脉

为什么是这个答案

凝血因子合成减少使 INR 升高。门静脉高压引起脾大伴血小板滞留，以及可能出血的曲张静脉。患者还可能有血栓倾向增加，所以这种平衡很复杂。

答案

D · 凝血因子减少、血小板低，以及门静脉高压引起的曲张静脉
14.内外科护理：消化、围手术期与肿瘤

答案: A · Stop and confirm identity, then apply a band

为什么是这个答案

Correct identification before anaesthesia prevents wrong-patient surgery. The process stops until identity is confirmed with the patient and records and a band is applied, following the checklist.

答案

A · Stop and confirm identity, then apply a band

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