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 with heart failure gained 2 kg (about 4 lb) since yesterday and is more breathless when lying down. What should the nurse do first?

  1. AAssess the lungs, oxygen saturation and swelling, then inform the provider
  2. BEncourage extra fluids to correct the weight change
  3. CRecord the weight on the chart and recheck it at the next weekly weigh-in
  4. DLay the patient flat to help them breathe more easily
2.优先排序与委派困难

An adult has burns over 40% of the body with no signs of airway injury. Which treatment is the priority during the first hours?

  1. AStarting physiotherapy to prevent contractures straight away
  2. BGiving a high-protein meal to support healing
  3. CApplying antibiotic cream to all the burns before anything else
  4. DLarge-volume IV fluids with close monitoring of urine output
3.感染控制与患者安全中等

A patient is on seizure precautions. Which equipment should be ready at the bedside?

  1. ARestraints ready for all four limbs
  2. BAn ice pack to place on the forehead
  3. CWorking suction and oxygen equipment
  4. DA tongue blade to put between the teeth
4.感染控制与患者安全困难

一名患有唇疱疹（herpes labialis）的护士被分配到新生儿室。最恰当的做法是什么？

  1. A戴上手套，照常工作
  2. B照常工作，因为唇疱疹很常见
  3. C不告诉任何人，上班时用化妆品遮住皮损
  4. D告知主管，主管可能暂时调整其工作安排
5.实验室检查值与电解质中等

A week after a splenectomy, a patient's platelet count is 650 × 10³/µL. What is the best interpretation?

  1. AA laboratory error, because platelets fall after splenectomy
  2. BAn expected rise after splenectomy that increases clot risk
  3. CA sign of new leukemia that needs immediate chemotherapy
  4. DA sign of iron overload from the surgery and transfusion
6.实验室检查值与电解质困难

A patient with a stable INR on warfarin starts rifampin (rifampicin) for tuberculosis. Two weeks later the INR is 1.3. What is the most likely explanation?

  1. ARifampin raises the INR, so it is wrong
  2. BRifampin contains a lot of vitamin K
  3. CRifampin speeds up warfarin metabolism
  4. DTuberculosis causes the INR to fall
7.临床护理中等

A patient on insulin reports nightmares, night sweats and morning headaches. What should be suspected?

  1. AA urinary tract infection
  2. BHyperthyroidism
  3. CRaised intracranial pressure
  4. DNight-time hypoglycaemia
8.临床护理困难

A nurse teaches a patient with a new ileostomy. Which statement shows a need for further teaching?

  1. A"I will drink extra fluids when it is hot."
  2. B"I will empty the bag when it is about a third to half full."
  3. C"My output will be firm and formed like before."
  4. D"My stoma should look pink or red and moist."
9.内外科护理：心血管与呼吸中等

How is a patient usually positioned for a thoracentesis?

  1. AFlat on the back with the legs raised
  2. BSitting upright and leaning forward over a table
  3. CProne with the arms by the sides
  4. DLying on the affected side with the head down
10.内外科护理：心血管与呼吸困难

A smoker has severe shoulder and arm pain, a drooping eyelid, a small pupil and reduced sweating on the same side of the face. What should be suspected?

  1. AA tumour at the apex of the lung (Pancoast tumour)
  2. BA frozen shoulder with referred pain to the face
  3. CA simple migraine
  4. DA stroke affecting the brainstem on the opposite side
11.内外科护理：神经、内分泌与肾脏中等

Several hours after a carotid endarterectomy, which finding needs the most urgent action?

  1. AMild pain at the incision site
  2. BAn expanding neck swelling with noisy breathing
  3. CA small amount of dried blood on the dressing
  4. DA blood pressure slightly above the baseline
12.内外科护理：神经、内分泌与肾脏困难

A nurse teaches a patient with Hashimoto's thyroiditis about levothyroxine. Which statement shows a need for further teaching?

  1. A"I will have regular blood tests to check my dose."
  2. B"I can stop the tablets once I feel back to normal."
  3. C"I will report palpitations or chest pain."
  4. D"I will take the tablets at the same time each day."
13.内外科护理：消化、围手术期与肿瘤中等

A patient received IV morphine 20 minutes ago and the surgical consent form has not been signed. What should the nurse do?

  1. AAsk the patient to sign quickly before they get sleepier
  2. BSign the form on the patient's behalf as a witness
  3. CTell the surgeon, as the patient may not be able to consent now
  4. DAsk a relative to sign instead of the patient
14.内外科护理：消化、围手术期与肿瘤困难

Which new prescription for a patient with cirrhosis should the nurse question?

  1. ARegular ibuprofen for back pain
  2. BSpironolactone for ascites
  3. CThiamine supplements
  4. DLactulose to keep the bowels open

3溶液

1.优先排序与委派

答案: A · Assess the lungs, oxygen saturation and swelling, then inform the provider

为什么是这个答案

A rapid weight gain with orthopnea suggests fluid overload and worsening heart failure. The nurse assesses breathing and fluid status and informs the provider, who may adjust the diuretic.

答案

A · Assess the lungs, oxygen saturation and swelling, then inform the provider
2.优先排序与委派

答案: D · Large-volume IV fluids with close monitoring of urine output

为什么是这个答案

Once the airway is secure, the early priority in major burns is fluid resuscitation to prevent burn shock. Urine output is a key guide to whether enough fluid is being given.

答案

D · Large-volume IV fluids with close monitoring of urine output
3.感染控制与患者安全

答案: C · Working suction and oxygen equipment

为什么是这个答案

Suction and oxygen are kept ready to manage secretions and support breathing during or after a seizure. Nothing is put in the mouth, and restraints are not used because they can cause injury.

答案

C · Working suction and oxygen equipment
4.感染控制与患者安全

答案: D · 告知主管，主管可能暂时调整其工作安排

为什么是这个答案

单纯疱疹病毒可在新生儿中引起严重感染。有活动性皮损的工作人员应告知主管并遵循职业健康建议，这通常意味着在皮损愈合前避免接触新生儿和其他高危患者。

答案

D · 告知主管，主管可能暂时调整其工作安排
5.实验室检查值与电解质

答案: B · An expected rise after splenectomy that increases clot risk

为什么是这个答案

The spleen stores about a third of the platelets. After splenectomy, the count often rises (reactive thrombocytosis), which can increase the risk of thrombosis. The count is monitored, and the patient is assessed for signs of clots.核对依据: Platelet count · MedlinePlus (NIH) (2025); Platelet Tests · MedlinePlus (NIH) (2024)

答案

B · An expected rise after splenectomy that increases clot risk
6.实验室检查值与电解质

答案: C · Rifampin speeds up warfarin metabolism

为什么是这个答案

Rifampin induces liver enzymes that break down warfarin, so warfarin's effect falls and the INR drops, increasing clot risk. The INR is monitored closely and the dose adjusted; the reverse happens when rifampin is stopped.

答案

C · Rifampin speeds up warfarin metabolism
7.临床护理

答案: D · Night-time hypoglycaemia

为什么是这个答案

Nocturnal hypoglycaemia can cause sweating, restless sleep, nightmares and morning headache. Checking glucose overnight and reviewing insulin doses can confirm and correct it.

答案

D · Night-time hypoglycaemia
8.临床护理

答案: C · "My output will be firm and formed like before."

为什么是这个答案

Ileostomy output is liquid to porridge-like because it bypasses the colon. The other statements describe correct care: good hydration, emptying the bag before it is too heavy and recognising a healthy stoma.

答案

C · "My output will be firm and formed like before."
9.内外科护理：心血管与呼吸

答案: B · Sitting upright and leaning forward over a table

为什么是这个答案

Sitting upright and leaning forward on a bedside table widens the intercostal spaces at the back and lets the fluid settle at the base. If the patient cannot sit, lying on the unaffected side may be used.

答案

B · Sitting upright and leaning forward over a table
10.内外科护理：心血管与呼吸

答案: A · A tumour at the apex of the lung (Pancoast tumour)

为什么是这个答案

A tumour in the lung apex can invade the brachial plexus (shoulder and arm pain) and the sympathetic chain, causing Horner's syndrome (ptosis, miosis, reduced sweating). It is a classic presentation of lung cancer that needs urgent imaging.

答案

A · A tumour at the apex of the lung (Pancoast tumour)
11.内外科护理：神经、内分泌与肾脏

答案: B · An expanding neck swelling with noisy breathing

为什么是这个答案

A neck haematoma after carotid surgery can compress the airway quickly. It needs immediate senior help and may need the wound opened. Neurological checks for new stroke and cranial nerve damage are also part of routine care.

答案

B · An expanding neck swelling with noisy breathing
12.内外科护理：神经、内分泌与肾脏

答案: B · "I can stop the tablets once I feel back to normal."

为什么是这个答案

In Hashimoto's thyroiditis the gland is permanently damaged, so levothyroxine is usually lifelong. Feeling well shows that the dose is right, not that the disease is cured. Stopping causes symptoms to return.

答案

B · "I can stop the tablets once I feel back to normal."
13.内外科护理：消化、围手术期与肿瘤

答案: C · Tell the surgeon, as the patient may not be able to consent now

为什么是这个答案

Opioids and sedatives can impair understanding, so consent may not be valid. The surgeon is informed; consent is obtained when the patient has capacity, or other legal processes are followed in an emergency.

答案

C · Tell the surgeon, as the patient may not be able to consent now
14.内外科护理：消化、围手术期与肿瘤

答案: A · Regular ibuprofen for back pain

为什么是这个答案

NSAIDs can cause kidney injury, fluid retention and GI bleeding in cirrhosis and should be avoided. Paracetamol at a reduced, carefully reviewed dose is usually preferred for pain.

答案

A · Regular ibuprofen for back pain

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