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

在 START 分诊中，一名不能行走的成人每分钟呼吸 36 次。该伤员被归入哪一类？

  1. A黄色（延迟）
  2. B红色（立即）
  3. C黑色（期待观察）
  4. D绿色（轻伤）
2.优先排序与委派困难

A marathon runner is confused, with a temperature of 41 °C and hot skin. What is the priority?

  1. ARapid cooling while supporting airway and circulation
  2. BGiving an antipyretic tablet and waiting for it to work
  3. CWrapping the runner in a blanket to prevent shivering
  4. DAsking the runner to rest in the shade and drink slowly
3.感染控制与患者安全中等

Which IV fluid can be given with packed red blood cells in the same line?

  1. ALactated Ringer’s (Hartmann’s) solution
  2. B5% dextrose in water
  3. C0.9% sodium chloride
  4. D5% dextrose in 0.45% sodium chloride
4.感染控制与患者安全困难

A nurse teaches an older adult about preventing falls at home. Which statement shows a need for further teaching?

  1. A“I use night lights between my bedroom and the bathroom.”
  2. B“I keep small rugs in the hall so my feet stay warm.”
  3. C“I had grab bars put in next to the toilet.”
  4. D“I wear shoes with non-slip soles around the house.”
5.实验室检查值与电解质中等

A nurse completed the hepatitis B vaccine series. Which result shows protective immunity?

  1. AA raised ALT level
  2. BAnti-HBs of 10 mIU/mL or more
  3. CA positive IgM anti-HBc
  4. DA positive HBsAg test
6.实验室检查值与电解质困难

A patient has a continuous heparin infusion for a pulmonary embolism. A new nurse plans to adjust the infusion using today's INR of 1.1. What should the experienced nurse explain?

  1. AThe INR of 1.1 means the heparin rate must be doubled at once
  2. BThe INR is the correct test, and 1.1 means heparin is therapeutic
  3. CHeparin needs no laboratory monitoring once the infusion is started
  4. DHeparin is adjusted using the aPTT or anti-Xa level, not the INR
7.临床护理中等

A patient has a fentanyl patch for chronic pain. Which advice is correct?

  1. AKeep using the old patch with the new one
  2. BCut the patch in half if the pain improves, to lower the dose
  3. CApply the patch to broken skin for faster effect
  4. DAvoid heat sources such as hot water bottles over the patch
8.临床护理困难

During CPR for asystole, when should adrenaline (epinephrine) be given according to standard adult guidelines?

  1. ANever, because asystole is not treated with drugs
  2. BAs soon as IV or IO access is obtained, then every 3–5 minutes
  3. COnly after three shocks have been delivered by the defibrillator
  4. DOnly once the patient has a pulse again
9.内外科护理：心血管与呼吸中等

Why must inspired air be humidified for a patient with a tracheostomy?

  1. ADry air is needed to stop secretions forming in the trachea
  2. BHumidification prevents the cuff from deflating
  3. CHumidified air contains more oxygen than dry air at the same flow
  4. DThe nose and upper airway, which warm and moisten air, are bypassed
10.内外科护理：心血管与呼吸困难

A patient with asthma needs their reliever every three hours and their peak flow is falling well below their personal best. What does their action plan most likely advise?

  1. AStop the preventer inhaler for a few days to rest the lungs
  2. BDo extra exercise to open the airways
  3. CWait two weeks to see whether it improves without any change
  4. DFollow the worsening-asthma steps and get a same-day review
11.内外科护理：神经、内分泌与肾脏中等

A patient with myasthenia gravis wants to plan a busy day. Which advice fits the disease?

  1. ADo demanding tasks in the morning or when the drug works best
  2. BDo the hardest tasks in the evening when muscles are warmed up
  3. CExercise to exhaustion so the muscles get stronger quickly
  4. DAvoid rest periods, because rest makes the weakness worse
12.内外科护理：神经、内分泌与肾脏困难

A patient with an external ventricular drain sat up in bed without help. The drain stayed at its old height, and the drainage bag filled quickly. The patient now has a headache. What is the concern?

  1. AOverdrainage of CSF, so act per protocol and inform the team
  2. BUnderdrainage, so the drain should be lowered further
  3. CNo concern, because more drainage always lowers the ICP safely
  4. DAn infected drain, so the dressing should be removed
13.内外科护理：消化、围手术期与肿瘤中等

A nasogastric feeding tube appears blocked. What is usually the first step?

  1. ACut the end of the tube to release the blockage inside it
  2. BUse a small 5 mL syringe with firm pressure
  3. CFlush gently with warm water in a 50 mL enteral syringe
  4. DPush the guidewire back in to clear it
14.内外科护理：消化、围手术期与肿瘤困难

Just after extubation in recovery, a patient develops a high-pitched noise on breathing in, with falling SpO₂. What should the nurse do first?

  1. ASit the patient up and give a drink of water
  2. BCall for help, give 100% oxygen and use a jaw thrust
  3. CWait a few minutes to see if it passes
  4. DGive an opioid to calm the patient's breathing and reduce anxiety

3溶液

1.优先排序与委派

答案: B · 红色（立即）

为什么是这个答案

在 START 中，呼吸频率超过 30 次/分意味着伤员被标为立即（红色）。30 次或以下则继续进行灌注和意识状态检查。

答案

B · 红色（立即）
2.优先排序与委派

答案: A · Rapid cooling while supporting airway and circulation

为什么是这个答案

Heat stroke is an emergency in which body temperature rises and the brain is affected. Rapid cooling, for example with cold water or ice, is the priority; antipyretics do not work for heat stroke.

答案

A · Rapid cooling while supporting airway and circulation
3.感染控制与患者安全

答案: C · 0.9% sodium chloride

为什么是这个答案

Only 0.9% sodium chloride is compatible with blood. Dextrose (glucose) solutions can cause red cells to clump and break down, and the calcium in lactated Ringer’s (Hartmann’s) can cause clotting.

答案

C · 0.9% sodium chloride
4.感染控制与患者安全

答案: B · “I keep small rugs in the hall so my feet stay warm.”

为什么是这个答案

Loose rugs are a common cause of trips and falls and should be removed or secured. Night lights, grab bars and non-slip footwear all reduce fall risk.

答案

B · “I keep small rugs in the hall so my feet stay warm.”
5.实验室检查值与电解质

答案: B · Anti-HBs of 10 mIU/mL or more

为什么是这个答案

An anti-HBs level of at least 10 mIU/mL after vaccination indicates protection. HBsAg and IgM anti-HBc indicate infection, not immunity. Health care workers are often tested after vaccination.

答案

B · Anti-HBs of 10 mIU/mL or more
6.实验室检查值与电解质

答案: D · Heparin is adjusted using the aPTT or anti-Xa level, not the INR

为什么是这个答案

Unfractionated heparin infusions are adjusted using the aPTT or anti-factor Xa level according to protocol. The INR monitors warfarin and is little affected by heparin at usual doses. Using the wrong test can cause under- or over-anticoagulation.

答案

D · Heparin is adjusted using the aPTT or anti-Xa level, not the INR
7.临床护理

答案: D · Avoid heat sources such as hot water bottles over the patch

为什么是这个答案

Heat increases absorption of fentanyl through the skin and can cause overdose. Old patches are removed and folded before disposal, and patches should not be cut unless the product allows it.

答案

D · Avoid heat sources such as hot water bottles over the patch
8.临床护理

答案: B · As soon as IV or IO access is obtained, then every 3–5 minutes

为什么是这个答案

In non-shockable rhythms, adrenaline is given as soon as possible and repeated every 3–5 minutes while CPR continues. In shockable rhythms it is given after the third shock in UK/European guidelines (after the second shock in AHA guidelines).

答案

B · As soon as IV or IO access is obtained, then every 3–5 minutes
9.内外科护理：心血管与呼吸

答案: D · The nose and upper airway, which warm and moisten air, are bypassed

为什么是这个答案

The tracheostomy bypasses the nose, mouth and pharynx, which warm, filter and humidify air. Without humidification, secretions become thick and can block the tube. Heat and moisture exchangers, humidified oxygen and nebulised saline are used.

答案

D · The nose and upper airway, which warm and moisten air, are bypassed
10.内外科护理：心血管与呼吸

答案: D · Follow the worsening-asthma steps and get a same-day review

为什么是这个答案

Personal asthma action plans set steps based on symptoms and peak flow compared with the personal best. Increasing reliever need and a falling peak flow mean worsening asthma: treatment is increased as the plan says (sometimes with oral steroids) and urgent review is sought. Severe signs need emergency care.

答案

D · Follow the worsening-asthma steps and get a same-day review
11.内外科护理：神经、内分泌与肾脏

答案: A · Do demanding tasks in the morning or when the drug works best

为什么是这个答案

In myasthenia gravis, muscles tire with use and recover with rest, so weakness is often worse later in the day. Planning demanding tasks for times of peak strength and building in rest helps.

答案

A · Do demanding tasks in the morning or when the drug works best
12.内外科护理：神经、内分泌与肾脏

答案: A · Overdrainage of CSF, so act per protocol and inform the team

为什么是这个答案

When the head rises above the drain level, CSF drains faster. Overdrainage can cause headache, collapse of the ventricles or a subdural bleed. The nurse follows the protocol (often clamping briefly and re-levelling) and informs the neurosurgical team.

答案

A · Overdrainage of CSF, so act per protocol and inform the team
13.内外科护理：消化、围手术期与肿瘤

答案: C · Flush gently with warm water in a 50 mL enteral syringe

为什么是这个答案

Gentle flushing with warm water using a 50 mL enteral syringe may clear a blockage. Small syringes and force can rupture the tube, and reinserting a guidewire can perforate the oesophagus.

答案

C · Flush gently with warm water in a 50 mL enteral syringe
14.内外科护理：消化、围手术期与肿瘤

答案: B · Call for help, give 100% oxygen and use a jaw thrust

为什么是这个答案

Stridor after extubation suggests laryngospasm or another upper airway obstruction. The nurse calls for help, applies high-flow oxygen and airway manoeuvres, and the anaesthetist may give drugs or reintubate.

答案

B · Call for help, give 100% oxygen and use a jaw thrust

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