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 is receiving a blood transfusion. Which task can the nurse delegate to a nursing assistant?

  1. AStarting the transfusion once the blood arrives
  2. BMeasuring and reporting vital signs at the times set by the nurse
  3. CAssessing the patient for signs of a transfusion reaction
  4. DDeciding whether to stop the transfusion if the patient has chills
2.优先排序与委派困难

一名头部受伤并伴有腿部骨折的患者正在接受监测。哪项发现是优先事项？

  1. A患者要求吃点东西
  2. B尽管刚用过镇痛药，腿痛仍为 6/10
  3. C格拉斯哥昏迷评分从 15 分降至 12 分
  4. D肘部有一处小擦伤
3.感染控制与患者安全中等

条码扫描器提示药物与患者记录不符。护士应怎么做？

  1. A扫描另一位患者的腕带
  2. B忽略警告并给药
  3. C暂停并查明原因后再给药
  4. D先给药，本班稍后再报告该警告
4.感染控制与患者安全困难

In US nursing practice, which task should the RN not assign to an LPN/LVN?

  1. AA dressing change on a healing surgical wound that has no signs of infection
  2. BGiving scheduled oral antibiotics to a stable patient
  3. CReinforcing hand hygiene teaching that the RN has already given
  4. DThe initial admission assessment of a new patient with suspected sepsis
5.实验室检查值与电解质中等

A patient takes low-dose methotrexate weekly for rheumatoid arthritis. Which laboratory tests are monitored regularly?

  1. ATroponin, creatine kinase and myoglobin
  2. BComplete blood count, liver tests and kidney function
  3. CSerum amylase, lipase and blood ketones
  4. DSerum lithium, sodium and urine specific gravity
6.实验室检查值与电解质困难

A child with sickle cell disease and a recent viral illness is pale and tired. The hemoglobin has fallen sharply, and the reticulocyte count is very low. What is the most likely problem?

  1. AIron deficiency from a poor diet over months
  2. BA vaso-occlusive pain crisis in the bones
  3. CA normal finding in sickle cell disease
  4. DAn aplastic crisis, often caused by parvovirus B19
7.临床护理中等

A patient with COPD and known carbon dioxide retention needs a nebulised bronchodilator. How should it usually be given?

  1. ADriven by compressed air, with oxygen given separately if needed
  2. BOnly with the patient lying flat
  3. CDriven by high-flow oxygen at 15 L/min for as long as possible
  4. DWithout monitoring oxygen saturation
8.临床护理困难

为什么浓氯化钾绝不能快速静脉推注？

  1. A会在静脉中结晶并堵塞留置针
  2. B可能引起致命性心律失常
  3. C会立即导致肾衰竭
  4. D快速给药时无效
9.内外科护理：心血管与呼吸中等

How big should a suction catheter be compared with the tracheostomy or endotracheal tube?

  1. ALarger than the tube, so that it clears it completely
  2. BExactly the same diameter as the tube, for a tight fit
  3. CNo more than half the internal diameter of the tube
  4. DAny size, as the diameter does not matter
10.内外科护理：心血管与呼吸困难

A patient with obstructive sleep apnoea who uses CPAP at home is having surgery. Which plan is safest after the operation?

  1. AGive extra opioids so the patient sleeps through the night
  2. BLeave the CPAP machine at home, as it is not needed while in hospital
  3. CUse their CPAP machine and monitor closely, using opioids with caution
  4. DNurse the patient lying flat on their back to keep the airway open
11.内外科护理：神经、内分泌与肾脏中等

Why are patients on haemodialysis vaccinated against hepatitis B?

  1. AHepatitis B vaccine improves the fistula flow
  2. BShared dialysis units carry a higher infection risk
  3. CThe vaccine is needed to make the dialyser work
  4. DThe vaccine lowers the potassium level
12.内外科护理：神经、内分泌与肾脏困难

A patient taking an SGLT2 inhibitor is booked for major surgery. Which statement is correct?

  1. AThe dose is usually doubled on the morning of surgery
  2. BThe drug must be taken right up until the operation starts
  3. CIt is usually paused in the days before surgery
  4. DSurgery is not possible in patients taking this drug
13.内外科护理：消化、围手术期与肿瘤中等

Why is an ankle-brachial pressure index (ABPI) measured before compression bandaging for a leg ulcer?

  1. ATo exclude significant arterial disease
  2. BTo check for a leg bone fracture
  3. CTo find the bacteria in the wound
  4. DTo find out how deep the ulcer is
14.内外科护理：消化、围手术期与肿瘤困难

After a fall, a patient with advanced dementia is agitated, grimacing and guarding the hip, and cannot rate the pain. What should the nurse do?

  1. AGive a sedative to treat the agitation and avoid giving any analgesia
  2. BWait until a relative can confirm the pain
  3. CUse an observational pain tool, give analgesia and reassess
  4. DAssume there is no pain because none is reported

3溶液

1.优先排序与委派

答案: B · Measuring and reporting vital signs at the times set by the nurse

为什么是这个答案

An assistant can measure vital signs and report them. Assessing for a reaction, starting the transfusion and deciding to stop it need the nurse’s judgement.

答案

B · Measuring and reporting vital signs at the times set by the nurse
2.优先排序与委派

答案: C · 格拉斯哥昏迷评分从 15 分降至 12 分

为什么是这个答案

GCS 下降提示颅内压升高，可能致命，需要紧急上报。骨折疼痛也需要处理，但不像这样威胁生命。

答案

C · 格拉斯哥昏迷评分从 15 分降至 12 分
3.感染控制与患者安全

答案: C · 暂停并查明原因后再给药

为什么是这个答案

条码警告的作用是发现患者错误、药物错误和剂量错误。护士应暂停，核对医嘱和药品，并联系药房或开医嘱者。出于习惯而忽略警告会导致差错。

答案

C · 暂停并查明原因后再给药
4.感染控制与患者安全

答案: D · The initial admission assessment of a new patient with suspected sepsis

为什么是这个答案

The initial assessment of a new, potentially unstable patient is an RN responsibility. LPNs/LVNs can give routine medications, perform routine procedures and reinforce teaching for stable patients.

答案

D · The initial admission assessment of a new patient with suspected sepsis
5.实验室检查值与电解质

答案: B · Complete blood count, liver tests and kidney function

为什么是这个答案

Methotrexate can cause bone marrow suppression, liver toxicity and, as it is cleared by the kidneys, toxicity when kidney function falls. The CBC, liver tests and creatinine are checked regularly, and folic acid is usually given to reduce adverse effects.核对依据: Methotrexate · StatPearls (NCBI Bookshelf) (2024)

答案

B · Complete blood count, liver tests and kidney function
6.实验室检查值与电解质

答案: D · An aplastic crisis, often caused by parvovirus B19

为什么是这个答案

Patients with sickle cell disease depend on a high reticulocyte count because their red cells live only a short time. Parvovirus B19 can stop red cell production for days, causing a rapid fall in hemoglobin with very low reticulocytes. Transfusion may be needed.核对依据: Reticulocyte Count · MedlinePlus (NIH) (2024)

答案

D · An aplastic crisis, often caused by parvovirus B19
7.临床护理

答案: A · Driven by compressed air, with oxygen given separately if needed

为什么是这个答案

Nebulisers driven by high-flow oxygen can raise PaCO2 in patients at risk. Air-driven nebulisers are used, with supplementary oxygen via nasal cannulae to keep saturation in the target range.

答案

A · Driven by compressed air, with oxygen given separately if needed
8.临床护理

答案: B · 可能引起致命性心律失常

为什么是这个答案

浓钾推注可使心脏停搏。钾必须稀释后以控制的速度给药，通常使用输液泵。

答案

B · 可能引起致命性心律失常
9.内外科护理：心血管与呼吸

答案: C · No more than half the internal diameter of the tube

为什么是这个答案

A catheter no larger than half the internal diameter of the tube lets air enter around it, reducing negative pressure in the lungs, atelectasis and hypoxaemia. Catheter size is often calculated from the tube size.

答案

C · No more than half the internal diameter of the tube
10.内外科护理：心血管与呼吸

答案: C · Use their CPAP machine and monitor closely, using opioids with caution

为什么是这个答案

Sedatives and opioids worsen airway collapse in OSA. Patients should bring and use their CPAP after surgery, be monitored with pulse oximetry, have opioid-sparing analgesia where possible and be nursed semi-upright or on their side.

答案

C · Use their CPAP machine and monitor closely, using opioids with caution
11.内外科护理：神经、内分泌与肾脏

答案: B · Shared dialysis units carry a higher infection risk

为什么是这个答案

Haemodialysis involves repeated vascular access in a shared unit, which raises the risk of blood-borne infection. Vaccination, screening and strict infection control protect patients and staff.

答案

B · Shared dialysis units carry a higher infection risk
12.内外科护理：神经、内分泌与肾脏

答案: C · It is usually paused in the days before surgery

为什么是这个答案

Fasting, surgery and dehydration increase the risk of euglycaemic DKA with SGLT2 inhibitors. Guidance usually advises stopping them in the days before major surgery and restarting when the patient is eating and drinking normally.

答案

C · It is usually paused in the days before surgery
13.内外科护理：消化、围手术期与肿瘤

答案: A · To exclude significant arterial disease

为什么是这个答案

ABPI compares ankle and arm systolic pressures. A low ABPI suggests arterial disease, where compression could cause ischaemia, so assessment is needed before compression therapy.

答案

A · To exclude significant arterial disease
14.内外科护理：消化、围手术期与肿瘤

答案: C · Use an observational pain tool, give analgesia and reassess

为什么是这个答案

In dementia, pain often appears as agitation or guarding. An observational tool supports assessment; analgesia is given and effect reassessed. The hip is also assessed for injury such as a fracture.

答案

C · Use an observational pain tool, give analgesia and reassess

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