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 receiving an aminoglycoside antibiotic, such as gentamicin, reports ringing in the ears. What should the nurse do?

  1. AAdvise the patient to use ear drops
  2. BHold the next dose and report it promptly
  3. CGive the next dose early to finish the course
  4. DReassure the patient that it is a normal effect
2.优先排序与委派困难

A patient with COPD on 2 L/min oxygen becomes drowsy and hard to wake. The SpO₂ is 93%. What is the priority?

  1. AAssess breathing and escalate for a blood gas, as carbon dioxide may be rising
  2. BLet the patient sleep, because the saturation is above target
  3. CGive the as-needed sedative so the patient rests comfortably
  4. DIncrease the oxygen to 6 L/min so that the saturation goes even higher than now
3.感染控制与患者安全中等

A small spill of blood is found on the floor. How should it be cleaned?

  1. AWipe it up quickly with a dry cloth using bare hands, then wash the hands well
  2. BWear gloves, absorb the blood, then clean the area with an approved disinfectant
  3. CCover it with a clean sheet and keep working
  4. DLeave it until housekeeping arrives the next morning
4.感染控制与患者安全困难

A patient has a rash, and both smallpox and chickenpox are considered. Which finding suggests smallpox?

  1. ALesions all at the same stage, most dense on the face and limbs
  2. BSmall crops of new lesions appearing over several days in a row
  3. CA rash that is very itchy and starts on the trunk
  4. DLesions at different stages, most dense on the trunk
5.实验室检查值与电解质中等

A healthy woman at 28 weeks of pregnancy has a mildly lower hemoglobin than before pregnancy, with a normal MCV and ferritin. What is the most likely explanation?

  1. APregnancy hormones stop the bone marrow from making red cells
  2. BIron is being lost through the kidneys during the pregnancy
  3. CThe fetus is destroying the mother's red cells in the circulation
  4. DPlasma volume rises more than red cell mass, diluting the blood
6.实验室检查值与电解质困难

The nurse teaches a patient with severe neutropenia after chemotherapy. Which statement shows a need for further teaching?

  1. A"I'll wash my hands before eating and after the toilet"
  2. B"I'll avoid people who have a cold or the flu"
  3. C"I'll check my temperature rectally to be accurate"
  4. D"I'll call the clinic if my temperature rises"
7.临床护理中等

What is the most common cause of hypernatraemia in frail older inpatients?

  1. AEating too much salt in one meal
  2. BNot drinking enough water
  3. CToo much exercise
  4. DTaking too many vitamins
8.临床护理困难

A patient with diabetes is found confused with slurred speech and weakness on one side. What should the nurse check first?

  1. ASerum cholesterol
  2. BBody mass index
  3. CUrine output for the last day
  4. DCapillary blood glucose
9.内外科护理：心血管与呼吸中等

一名近期卒中且吞咽困难的患者出现发热和右下肺湿啰音。最可能的原因是什么？

  1. A吸入性肺炎
  2. B肺栓塞
  3. C急性哮喘
  4. D左心衰竭
10.内外科护理：心血管与呼吸困难

A patient has new chest pain at rest. The ECG shows ST depression, but serial troponins remain normal. Which diagnosis fits best?

  1. AUnstable angina
  2. BNon-ST-elevation myocardial infarction
  3. CST-elevation myocardial infarction
  4. DStable angina
11.内外科护理：神经、内分泌与肾脏中等

A patient has a nephrostomy tube. Which finding needs urgent action?

  1. ASteady urine drainage into the bag
  2. BA dry, intact dressing at the site
  3. CDrainage that stops suddenly with new loin pain
  4. DLight pink urine on the first day after insertion
12.内外科护理：神经、内分泌与肾脏困难

A patient with nephrotic syndrome suddenly has loin pain, blood in the urine and a rise in creatinine. What is a likely cause?

  1. ARenal vein thrombosis
  2. BToo much dietary protein
  3. CA simple bladder infection
  4. DNormal fluctuation in the disease
13.内外科护理：消化、围手术期与肿瘤中等

限钠和螺内酯在肝硬化中起什么作用？

  1. A增加钾丢失并预防高钾血症
  2. B减少钠水潴留并控制腹水
  3. C升高血压并改善肾血流
  4. D降低血氨并治疗脑病
14.内外科护理：消化、围手术期与肿瘤困难

一名患者正在接受负压伤口治疗。泵报警，敷料失去了密封。最恰当的措施是什么？

  1. A在泡沫上用干纱布填塞伤口，并用胶带贴紧
  2. B把吸力调到最大设置以拉回密封
  3. C恢复密封；如果及时无法恢复，改用湿性敷料
  4. D把泡沫留在伤口内、不吸引，直到数天后复查

3溶液

1.优先排序与委派

答案: B · Hold the next dose and report it promptly

为什么是这个答案

Aminoglycosides can cause ototoxicity, which may be permanent. Tinnitus or hearing loss is reported promptly, and drug levels and kidney function are checked.

答案

B · Hold the next dose and report it promptly
2.优先排序与委派

答案: A · Assess breathing and escalate for a blood gas, as carbon dioxide may be rising

为什么是这个答案

In COPD, drowsiness can be a sign of carbon dioxide retention (hypercapnia), even when the saturation is acceptable. The nurse assesses breathing, escalates and avoids extra oxygen or sedatives that could worsen it.

答案

A · Assess breathing and escalate for a blood gas, as carbon dioxide may be rising
3.感染控制与患者安全

答案: B · Wear gloves, absorb the blood, then clean the area with an approved disinfectant

为什么是这个答案

Blood spills are cleaned promptly by staff wearing gloves. The blood is absorbed with disposable material, then the area is cleaned and disinfected with a hospital disinfectant, and waste goes into clinical waste.

答案

B · Wear gloves, absorb the blood, then clean the area with an approved disinfectant
4.感染控制与患者安全

答案: A · Lesions all at the same stage, most dense on the face and limbs

为什么是这个答案

In smallpox, lesions develop at the same stage in any one area and are densest on the face and extremities. In chickenpox, crops appear at different stages and are densest on the trunk.

答案

A · Lesions all at the same stage, most dense on the face and limbs
5.实验室检查值与电解质

答案: D · Plasma volume rises more than red cell mass, diluting the blood

为什么是这个答案

In pregnancy, plasma volume increases by more than red cell mass, so the hemoglobin falls slightly (physiologic or dilutional anemia). Iron deficiency is still common in pregnancy and is checked with the MCV and ferritin.核对依据: Anemia · StatPearls (NCBI Bookshelf) (2026)

答案

D · Plasma volume rises more than red cell mass, diluting the blood
6.实验室检查值与电解质

答案: C · "I'll check my temperature rectally to be accurate"

为什么是这个答案

Rectal temperatures, suppositories and enemas are avoided in neutropenia, because injury to the rectal mucosa can let bacteria into the blood. Prompt reporting of fever, hand hygiene and avoiding sick contacts are correct.

答案

C · "I'll check my temperature rectally to be accurate"
7.临床护理

答案: B · Not drinking enough water

为什么是这个答案

Hypernatraemia usually reflects water deficit, often in patients who are confused, unable to drink independently or losing fluid through fever or diarrhoea. Supporting fluid intake prevents it.

答案

B · Not drinking enough water
8.临床护理

答案: D · Capillary blood glucose

为什么是这个答案

Hypoglycaemia can cause focal neurological signs that mimic stroke. A bedside glucose check is quick and should be done in any patient with sudden neurological symptoms.

答案

D · Capillary blood glucose
9.内外科护理：心血管与呼吸

答案: A · 吸入性肺炎

为什么是这个答案

卒中后的吞咽困难增加了误吸的风险。误吸物常进入右下叶，因为右主支气管更宽、更垂直。吞咽筛查、直立体位和口腔护理可降低风险。

答案

A · 吸入性肺炎
10.内外科护理：心血管与呼吸

答案: A · Unstable angina

为什么是这个答案

Unstable angina is new, worsening or rest angina without a troponin rise. It is an acute coronary syndrome and is managed urgently because it can progress to infarction. Stable angina is predictable and exertional. NSTEMI has a rising troponin.

答案

A · Unstable angina
11.内外科护理：神经、内分泌与肾脏

答案: C · Drainage that stops suddenly with new loin pain

为什么是这个答案

A sudden stop in drainage with pain suggests the tube is blocked or dislodged, so the kidney is obstructed again. The nurse checks for kinks and escalates urgently. Fever or rigors may signal infection.

答案

C · Drainage that stops suddenly with new loin pain
12.内外科护理：神经、内分泌与肾脏

答案: A · Renal vein thrombosis

为什么是这个答案

Loss of anticoagulant proteins in nephrotic syndrome raises the risk of thrombosis, including in the renal vein. This can cause loin pain, haematuria and worse kidney function. Imaging and anticoagulation are needed.

答案

A · Renal vein thrombosis
13.内外科护理：消化、围手术期与肿瘤

答案: B · 减少钠水潴留并控制腹水

为什么是这个答案

在肝硬化中，继发性醛固酮增多症引起钠水潴留。限钠和醛固酮拮抗剂螺内酯（常与袢利尿剂联用）可减少腹水。螺内酯可引起高钾血症和男性乳房发育。

答案

B · 减少钠水潴留并控制腹水
14.内外科护理：消化、围手术期与肿瘤

答案: C · 恢复密封；如果及时无法恢复，改用湿性敷料

为什么是这个答案

NPWT 需要气密的密封。如果密封或吸力丧失且不能及时恢复（许多指南规定约 2 小时内），应取出泡沫并换成标准敷料，以降低感染风险。安全间隔由制造商和当地指南规定。

答案

C · 恢复密封；如果及时无法恢复，改用湿性敷料

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