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

During a blood transfusion, a patient develops chills, back pain and a fever. What is the nurse’s first action?

  1. AFinish the unit quickly through a pressure bag so that the reaction does not last long
  2. BSlow the transfusion and recheck in an hour
  3. CGive an antipyretic and continue the transfusion
  4. DStop the transfusion and keep the IV open with normal saline via new tubing
2.优先排序与委派困难

A patient taking an SSRI is also given tramadol. A few hours later the patient is agitated, sweating and has a fever, jerking muscles and brisk reflexes. What is the most likely cause?

  1. AOpioid withdrawal
  2. BSerotonin syndrome
  3. CAn anxiety attack
  4. DNeuroleptic malignant syndrome
3.感染控制与患者安全中等

Where should the dispersive (grounding) pad for electrosurgery be placed?

  1. AOver a bony prominence such as the hip bone
  2. BOver an area with scar tissue or a tattoo, so that the pad does not slip
  3. COn clean, dry skin over a well-perfused muscle, close to the surgical site
  4. DOn skin that is wet with antiseptic prep
4.感染控制与患者安全困难

A patient is on contact precautions. Which task is appropriate for the nurse to delegate to assistive personnel?

  1. ADeciding when the precautions can be stopped
  2. BHelping the patient bathe while wearing a gown and gloves
  3. CAssessing the wound for new signs of infection during the bath
  4. DTeaching the family how to follow the precautions
5.实验室检查值与电解质中等

一名患者接受皮下注射依诺肝素（一种低分子量肝素）。关于监测，哪项说法是正确的？

  1. A不常规监测 aPTT；而是检查血小板和肾功能
  2. B像华法林一样，用 INR 调整每次剂量
  3. C任何时候都不需要任何血液检查
  4. D必须每 6 小时检查 aPTT 来调整剂量
6.实验室检查值与电解质困难

Ten days after chemotherapy, a patient has a platelet count of 9 × 10³/µL and reports a sudden severe headache and blurred vision. What is the priority?

  1. AAssess neurological status and report it at once as possible brain bleeding
  2. BDim the lights and encourage rest, as headaches are common after chemotherapy
  3. CEncourage the patient to drink more fluids and check the blood pressure later
  4. DGive acetaminophen (paracetamol) for the headache and reassess in 1 hour
7.临床护理中等

Which advice is important for a patient on long-term oral corticosteroids?

  1. ATake them only when symptoms flare
  2. BTake them on an empty stomach at night
  3. CDouble the dose if a dose is missed
  4. DDo not stop them suddenly
8.临床护理困难

A patient going home with a leg cast is taught about cast care. Which statement shows a need for further teaching?

  1. A"I will come back if my toes go numb or turn blue."
  2. B"I will keep the cast dry."
  3. C"I can push a knitting needle down the cast to scratch an itch."
  4. D"I will keep my leg raised on pillows for the first few days."
9.内外科护理：心血管与呼吸中等

关于定量吸入器的储雾罐，下列哪项说法正确？

  1. A所需的协调动作较少，更多药物到达肺部
  2. B它意味着可以完全停用类固醇预防型吸入器
  3. C它是为干粉吸入器设计的
  4. D它使每次喷出的药物比平时更强
10.内外科护理：心血管与呼吸困难

一名心房颤动患者心率 165 次/分，血压 78/45 mmHg，胸痛并出现新的意识混乱。护士应预期哪种治疗？

  1. A像心脏骤停那样进行非同步除颤
  2. B静脉注射阿托品以改善血压
  3. C口服比索洛尔，明早复查
  4. D紧急同步电复律
11.内外科护理：神经、内分泌与肾脏中等

Which measure best prevents catheter-associated urinary tract infection?

  1. ARemove the catheter as soon as it is no longer needed
  2. BKeep the drainage bag above bladder level
  3. CDisconnect the bag regularly to empty it
  4. DChange the catheter for a new one every day
12.内外科护理：神经、内分泌与肾脏困难

A nurse teaches a wheelchair user with a spinal cord injury about skin care. Which statement shows a need for further teaching?

  1. A"I only need to check my skin when something hurts."
  2. B"I will shift my weight in the chair regularly."
  3. C"I will keep my skin clean and dry."
  4. D"I will use a mirror to check my bottom and heels every day."
13.内外科护理：消化、围手术期与肿瘤中等

Why is a pregnancy test often done before surgery in women who could be pregnant?

  1. AIt is needed to calculate the anaesthetic drug dose
  2. BPregnancy always makes surgery impossible
  3. CAnaesthesia, drugs and some tests may harm a fetus
  4. DPregnant women cannot sign consent forms
14.内外科护理：消化、围手术期与肿瘤困难

A patient on warfarin has a major upper GI bleed with an INR of 5. Which treatment should the nurse anticipate to reverse the warfarin?

  1. AProtamine sulfate on its own
  2. BOral aspirin to balance the clotting system quickly
  3. CProthrombin complex concentrate with IV vitamin K
  4. DMore warfarin to stabilise the INR

3溶液

1.优先排序与委派

答案: D · Stop the transfusion and keep the IV open with normal saline via new tubing

为什么是这个答案

For any suspected transfusion reaction, the nurse stops the transfusion at once, keeps the vein open with normal saline through new tubing and informs the provider and blood bank.

答案

D · Stop the transfusion and keep the IV open with normal saline via new tubing
2.优先排序与委派

答案: B · Serotonin syndrome

为什么是这个答案

SSRIs and tramadol both raise serotonin. Agitation, fever, clonus and hyperreflexia that start quickly suggest serotonin syndrome; neuroleptic malignant syndrome follows antipsychotics and causes rigid muscles with slow reflexes.

答案

B · Serotonin syndrome
3.感染控制与患者安全

答案: C · On clean, dry skin over a well-perfused muscle, close to the surgical site

为什么是这个答案

The pad returns the current safely. Good contact over a well-perfused muscle prevents burns, while bony areas, scars, hair and moisture reduce contact and can cause burns at the pad site.

答案

C · On clean, dry skin over a well-perfused muscle, close to the surgical site
4.感染控制与患者安全

答案: B · Helping the patient bathe while wearing a gown and gloves

为什么是这个答案

Assistive personnel can carry out routine care for a stable patient, using the correct PPE. Assessment, teaching and clinical judgement, such as deciding when to stop precautions, cannot be delegated to them.

答案

B · Helping the patient bathe while wearing a gown and gloves
5.实验室检查值与电解质

答案: A · 不常规监测 aPTT；而是检查血小板和肾功能

为什么是这个答案

依诺肝素的效果可预测，因此不用 aPTT 来监测。血小板计数有助于发现肝素诱导的血小板减少症，肾功能也很重要，因为该药经肾脏清除。在妊娠、肥胖或肾病时可使用抗 Xa 水平。

答案

A · 不常规监测 aPTT；而是检查血小板和肾功能
6.实验室检查值与电解质

答案: A · Assess neurological status and report it at once as possible brain bleeding

为什么是这个答案

Platelet counts usually reach their lowest point (nadir) about 7–14 days after chemotherapy. With a count below 10 × 10³/µL, a sudden severe headache or visual change may signal intracranial bleeding, which is an emergency. The nurse assesses neurological status and reports it immediately.核对依据: Bleeding and Bruising (Thrombocytopenia) and Cancer Treatment · National Cancer Institute (NIH) (2022); Pancytopenia · StatPearls (NCBI Bookshelf) (2023)

答案

A · Assess neurological status and report it at once as possible brain bleeding
7.临床护理

答案: D · Do not stop them suddenly

为什么是这个答案

Long-term steroids suppress the adrenal glands, so stopping suddenly can cause adrenal crisis. Patients should carry a steroid alert card or medical ID and follow sick-day guidance.

答案

D · Do not stop them suddenly
8.临床护理

答案: C · "I can push a knitting needle down the cast to scratch an itch."

为什么是这个答案

Pushing objects under a cast can injure the skin and cause infection or pressure sores. Elevation, keeping the cast dry and reporting numbness, colour change or increasing pain are correct.

答案

C · "I can push a knitting needle down the cast to scratch an itch."
9.内外科护理：心血管与呼吸

答案: A · 所需的协调动作较少，更多药物到达肺部

为什么是这个答案

储雾罐使气雾减速并将其留存，让患者可以缓慢呼吸吸入。更多药物到达肺部，沉积在口腔的减少。它与加压定量吸入器配合使用，而不用于干粉装置。

答案

A · 所需的协调动作较少，更多药物到达肺部
10.内外科护理：心血管与呼吸

答案: D · 紧急同步电复律

为什么是这个答案

伴有不良特征（休克、心肌缺血、晕厥或心力衰竭）的快速性心律失常，需要在镇静或麻醉下紧急同步直流电复律。电击与 R 波同步，以避免触发室颤。非同步除颤用于无脉搏的心律，阿托品用于心动过缓。

答案

D · 紧急同步电复律
11.内外科护理：神经、内分泌与肾脏

答案: A · Remove the catheter as soon as it is no longer needed

为什么是这个答案

The risk of CAUTI rises with each day a catheter is in place. Avoiding unnecessary catheters and removing them early are the most effective measures. A closed system and keeping the bag below bladder level also help.

答案

A · Remove the catheter as soon as it is no longer needed
12.内外科护理：神经、内分泌与肾脏

答案: A · "I only need to check my skin when something hurts."

为什么是这个答案

Patients usually cannot feel pain below the injury, so pain cannot warn them of pressure damage. They need daily skin checks, often with a mirror, regular pressure relief and good skin hygiene.

答案

A · "I only need to check my skin when something hurts."
13.内外科护理：消化、围手术期与肿瘤

答案: C · Anaesthesia, drugs and some tests may harm a fetus

为什么是这个答案

Unknown pregnancy can change the decision to operate, the timing, and the choice of drugs and X-rays. Testing is offered with consent, according to local policy.

答案

C · Anaesthesia, drugs and some tests may harm a fetus
14.内外科护理：消化、围手术期与肿瘤

答案: C · Prothrombin complex concentrate with IV vitamin K

为什么是这个答案

Major bleeding on warfarin is treated by stopping it and giving prothrombin complex concentrate for rapid reversal with IV vitamin K for a lasting effect. Protamine reverses heparin, not warfarin.

答案

C · Prothrombin complex concentrate with IV vitamin K

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