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 had a colostomy formed yesterday. Which stoma appearance should be reported straight away?

  1. AA little bleeding when cleaned
  2. BDark purple or black
  3. CSlightly swollen
  4. DMoist and pink-red
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. ABowel sounds in all four abdominal quadrants
  2. BAbility to feed themselves
  3. CSkin over the sacrum and heels
  4. DBreathing effort and ability to cough
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. CThe family must wait for the next scheduled ward round to raise the concern with a doctor
  4. DOnly doctors may call the rapid response team
4.感染控制与患者安全困难

给一名有窒息风险的清醒患者口服药物。哪种做法最安全？

  1. A让患者仰卧平躺，使吞咽更容易
  2. B不检查是否允许就把所有药片碾碎
  3. C为节省时间一次给完所有药片
  4. D让患者坐直，一次给一片药
5.实验室检查值与电解质中等

When should a blood specimen tube be labeled?

  1. AAt the nurses' station, after all samples for the shift are drawn
  2. BBefore entering the room, so tubes are ready for the next patients
  3. CAt the bedside, in the patient's presence, using two identifiers
  4. DIn the laboratory, by the staff who receive the unlabeled sample
6.实验室检查值与电解质困难

A patient on a stable dose of levothyroxine now has a TSH of 9.8 mIU/L. She recently started taking her calcium and iron supplements with her morning levothyroxine. What is the most likely explanation?

  1. AThe TSH is low, showing that the dose is now too high
  2. BThe result is normal for a person on levothyroxine therapy
  3. CThe supplements are causing an overactive thyroid gland
  4. DThe supplements are reducing levothyroxine absorption
7.临床护理中等

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

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

一名头部外伤患者出现血压升高、心率减慢和呼吸不规则。这提示：

  1. A颅内压增高（库欣三联征）
  2. B隐匿性内出血引起的低血容量性休克
  3. C脓毒症
  4. D惊恐发作
9.内外科护理：心血管与呼吸中等

A patient who had a stroke has a weak swallow. Which measure most reduces the risk of aspiration pneumonia?

  1. ALying flat for 30 minutes after eating to aid digestion
  2. BA swallowing assessment and sitting upright for meals
  3. CGiving meals while the patient is drowsy
  4. DGiving thin fluids quickly through a straw between meals
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

A patient on insulin asks about drinking alcohol. Which advice is correct?

  1. AAlcohol raises glucose, so extra insulin should be taken first
  2. BAlcohol should replace a meal on the days it is drunk
  3. CAlcohol can cause hypos, even the next day, so eat carbs with it
  4. DAlcohol has no effect on blood glucose in people with diabetes
12.内外科护理：神经、内分泌与肾脏困难

Four patients had a minor head injury with no loss of consciousness and a GCS of 15. Which one most needs a CT scan of the head?

  1. AA 78-year-old who takes warfarin for atrial fibrillation
  2. BA 40-year-old with a mild headache that is improving
  3. CA 30-year-old who bumped their head on a cupboard door
  4. DA 25-year-old with a small scalp graze after a fall
13.内外科护理：消化、围手术期与肿瘤中等

A patient had an upper GI endoscopy with a local anaesthetic throat spray. What must the nurse check before giving a drink?

  1. AThat the patient's blood glucose is above normal
  2. BThat the patient has passed urine since the procedure
  3. CThat swallowing and the gag reflex have returned
  4. DThat bowel sounds are present in all four quadrants
14.内外科护理：消化、围手术期与肿瘤困难

Which preoperative task can a registered nurse usually delegate to a healthcare assistant (nursing assistant)?

  1. ADeciding whether abnormal results need reporting
  2. BAssessing the patient's understanding of the surgery
  3. CTeaching the patient how to use a PCA pump
  4. DRecording baseline vital signs

3溶液

1.优先排序与委派

答案: B · Dark purple or black

为什么是这个答案

A healthy stoma is moist and pink to red, and early swelling or slight bleeding is common. A dark purple or black stoma suggests poor blood supply (ischemia) and needs urgent review.

答案

B · Dark purple or black
2.优先排序与委派

答案: D · 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

D · 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: D · 让患者坐直，一次给一片药

为什么是这个答案

直立体位和一次给一种药可降低窒息风险。只有在药房确认安全后才可碾碎，因为一些缓释和肠溶制剂碾碎后会有危险。

答案

D · 让患者坐直，一次给一片药
5.实验室检查值与电解质

答案: C · At the bedside, in the patient's presence, using two identifiers

为什么是这个答案

Specimens are labeled immediately after collection, at the bedside, after checking two patient identifiers such as name and date of birth. Pre-labeling or labeling away from the patient can put the wrong patient's name on the sample, which can lead to harmful decisions.

答案

C · At the bedside, in the patient's presence, using two identifiers
6.实验室检查值与电解质

答案: D · The supplements are reducing levothyroxine absorption

为什么是这个答案

Calcium, iron and antacids bind levothyroxine in the gut and reduce absorption, so the TSH rises. Levothyroxine is taken on an empty stomach, usually 30–60 minutes before breakfast, separated from these supplements by about 4 hours.

答案

D · The supplements are reducing levothyroxine absorption
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: A · 颅内压增高（库欣三联征）

为什么是这个答案

库欣三联征（高血压伴脉压增大、心动过缓和呼吸不规则）是颅内压增高的晚期征象，需要紧急处理。

答案

A · 颅内压增高（库欣三联征）
9.内外科护理：心血管与呼吸

答案: B · A swallowing assessment and sitting upright for meals

为什么是这个答案

Patients with dysphagia need a formal swallowing assessment, food and fluid textures that are safe for them, sitting upright during and after meals and close supervision. Good oral hygiene also reduces the bacterial load that can be aspirated.

答案

B · A swallowing assessment and sitting upright for meals
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: C · Alcohol can cause hypos, even the next day, so eat carbs with it

为什么是这个答案

Alcohol reduces the liver's release of glucose, so it increases the risk of hypoglycaemia, which may be delayed for many hours. Patients should eat carbohydrate, check glucose before bed and tell friends that a hypo can look like drunkenness.

答案

C · Alcohol can cause hypos, even the next day, so eat carbs with it
12.内外科护理：神经、内分泌与肾脏

答案: A · A 78-year-old who takes warfarin for atrial fibrillation

为什么是这个答案

Anticoagulation greatly increases the risk of an intracranial bleed after even a minor head injury, and older age adds to the risk. These patients have a low threshold for a CT scan, even when they appear well.

答案

A · A 78-year-old who takes warfarin for atrial fibrillation
13.内外科护理：消化、围手术期与肿瘤

答案: C · That swallowing and the gag reflex have returned

为什么是这个答案

Throat spray numbs the pharynx, so drinking too early risks aspiration. Fluids are given once the gag reflex and swallowing have returned, usually after about an hour, starting with sips of water.

答案

C · That swallowing and the gag reflex have returned
14.内外科护理：消化、围手术期与肿瘤

答案: D · Recording baseline vital signs

为什么是这个答案

Trained assistants can record routine observations and report them. Assessment, teaching and interpreting results need registered nurse knowledge and judgement.

答案

D · Recording baseline vital signs

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