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

Several patients on a gastroenterology unit need care. Which patient should the nurse see first?

  1. ATwo hours after a colonoscopy: rigid abdomen and severe new pain
  2. BUlcerative colitis, asking about diet changes for home
  3. CCrohn disease, waiting to be taken down for a scheduled CT scan
  4. DLong-standing back pain, asking for the usual analgesic
2.优先排序与委派困难

一名 LPN/LVN 报告说一名稳定的患者现在出现新的胸痛。RN 应怎么做？

  1. A让 LPN/LVN 处理，并在班次结束时回报
  2. B让护理助理做心电图并等待结果
  3. C告诉 LPN/LVN 不经评估就给予按需使用的硝酸甘油
  4. D亲自评估患者并决定下一步
3.感染控制与患者安全中等

How should a portable oxygen cylinder be kept in a patient’s room?

  1. ALying loose on the floor beside the bed
  2. BPlaced next to a heater to keep it warm
  3. CLaid on the bed next to the patient
  4. DSecured upright in a stand or holder
4.感染控制与患者安全困难

During bedside handoff, the patient says, “I’m allergic to sulfa drugs,” but no allergy is recorded. What should the nurse do?

  1. ATell the patient that sulfa drugs are always safe
  2. BWait until the patient is discharged to update the record
  3. CIgnore it, because the electronic record is more reliable than the patient’s memory
  4. DClarify the reaction, update the allergy record and tell the prescriber
5.实验室检查值与电解质中等

为什么对血清白蛋白低的患者，必须谨慎解读偏低的总钙？

  1. A白蛋白和钙用同一种化学反应测定，所以总是一起下降
  2. B白蛋白低总会导致真正有症状的低钙血症
  3. C白蛋白低使所有钙检测都不准确、毫无用处
  4. D许多钙与白蛋白结合，因此即使离子钙正常，总钙也会下降
6.实验室检查值与电解质困难

A patient with sepsis has the following new results. Which set best shows organ dysfunction?

  1. AHemoglobin 12.5 g/dL, sodium 138 mEq/L, glucose 105 mg/dL
  2. BCalcium 9.4 mg/dL, phosphate 3.5 mg/dL, magnesium 1.9 mEq/L
  3. CPlatelets 70 × 10³/µL, creatinine doubled, bilirubin raised
  4. DWBC 11.5 × 10³/µL, potassium 4.2 mEq/L, albumin 3.8 g/dL
7.临床护理中等

A nurse gives a patient analgesia for post-operative pain. What should be done next?

  1. AGive a second analgesic straight away just in case
  2. BAssume the pain has gone if the patient is quiet and has their eyes closed
  3. CReassess the pain and any side effects once the drug has had time to work
  4. DWait until the next shift before asking the patient about the pain
8.临床护理困难

Soon after starting chemotherapy for a high-grade lymphoma, a patient has rising potassium, phosphate and uric acid with falling urine output. What is the most likely cause?

  1. AAdrenal insufficiency
  2. BSyndrome of inappropriate ADH secretion
  3. CRefeeding syndrome
  4. DTumour lysis syndrome
9.内外科护理：心血管与呼吸中等

A patient has exercise-induced asthma. Which advice is most appropriate?

  1. AAvoid all forms of exercise permanently to prevent attacks
  2. BExercise only in cold, dry air to toughen the airways
  3. CUse the reliever inhaler shortly before exercise and warm up
  4. DTake a beta-blocker before exercise
10.内外科护理：心血管与呼吸困难

一名哮喘患者的峰流速为其最佳值的 40%，呼吸频率 28 次/分，不能说完整句子。SpO₂ 94%。该次发作应如何分级？

  1. A急性重度哮喘
  2. B濒死性哮喘
  3. C中度哮喘加重
  4. D危及生命的哮喘
11.内外科护理：神经、内分泌与肾脏中等

A patient taking a GLP-1 receptor agonist has severe, constant upper abdominal pain spreading to the back, with vomiting. What should the nurse suspect?

  1. AA simple urinary tract infection
  2. BNormal nausea from the drug
  3. CLow blood glucose
  4. DAcute pancreatitis
12.内外科护理：神经、内分泌与肾脏困难

A student has fever, a severe headache, a spreading non-blanching rash and a BP of 85/50 mmHg. A lumbar puncture is planned. What is the priority?

  1. AArrange a CT scan of the head before any treatment
  2. BGive paracetamol (acetaminophen) and recheck observations in an hour
  3. CWait until after the lumbar puncture before giving antibiotics
  4. DGive IV antibiotics at once and start sepsis treatment
13.内外科护理：消化、围手术期与肿瘤中等

Which presentation fits acute diverticulitis?

  1. ARight upper abdominal pain after fatty meals
  2. BPainless jaundice with a palpable gallbladder
  3. CLeft lower abdominal pain, fever and a raised CRP
  4. DCentral chest pain spreading to the left arm
14.内外科护理：消化、围手术期与肿瘤困难

一名两个月前放置了冠状动脉支架、服用阿司匹林和氯吡格雷的患者出现黑便，现在情况稳定。对抗血小板药物，最恰当的处理是什么？

  1. A将两种药物的剂量加倍，因为出血意味着支架有更大的血栓风险
  2. B报告出血；由团队在心脏科的参与下决定，权衡出血与支架血栓
  3. C永久停用两种药物，因为任何出血都意味着它们不再安全
  4. D两种药物原样继续，并且不向团队提及出血

3溶液

1.优先排序与委派

答案: A · Two hours after a colonoscopy: rigid abdomen and severe new pain

为什么是这个答案

A rigid abdomen with severe pain after colonoscopy suggests bowel perforation and peritonitis, a surgical emergency. The other patients have stable, chronic or routine needs.

答案

A · Two hours after a colonoscopy: rigid abdomen and severe new pain
2.优先排序与委派

答案: D · 亲自评估患者并决定下一步

为什么是这个答案

当稳定的患者出现新问题时，RN 应评估患者，因为患者现在可能不稳定。然后 RN 决定干预措施和上报，可能包括心电图和处方的硝酸甘油。

答案

D · 亲自评估患者并决定下一步
3.感染控制与患者安全

答案: D · Secured upright in a stand or holder

为什么是这个答案

Oxygen cylinders are under high pressure and can be damaged or cause injury if they fall. They are kept upright in a holder or cart, away from heat and flames.

答案

D · Secured upright in a stand or holder
4.感染控制与患者安全

答案: D · Clarify the reaction, update the allergy record and tell the prescriber

为什么是这个答案

Bedside handoff lets patients correct errors. The nurse asks about the reaction, updates the record and alerts the prescriber and pharmacy so current and future orders can be checked.

答案

D · Clarify the reaction, update the allergy record and tell the prescriber
5.实验室检查值与电解质

答案: D · 许多钙与白蛋白结合，因此即使离子钙正常，总钙也会下降

为什么是这个答案

约 40–45% 的钙与血浆蛋白结合，主要是白蛋白。白蛋白低时，总钙下降，而离子钙可能正常。校正钙或实测离子钙才能反映真实情况。核对依据: Hypocalcemia (StatPearls) · StatPearls (NCBI Bookshelf) (2026)

答案

D · 许多钙与白蛋白结合，因此即使离子钙正常，总钙也会下降
6.实验室检查值与电解质

答案: C · Platelets 70 × 10³/µL, creatinine doubled, bilirubin raised

为什么是这个答案

In sepsis, falling platelets (coagulation), a rising creatinine (kidney) and a raised bilirubin (liver) show organ dysfunction, which indicates severe disease. The other sets are normal or near normal.核对依据: Bacterial Sepsis · StatPearls (NCBI Bookshelf) (2023); Laboratory Evaluation of Sepsis · StatPearls (NCBI Bookshelf) (2023)

答案

C · Platelets 70 × 10³/µL, creatinine doubled, bilirubin raised
7.临床护理

答案: C · Reassess the pain and any side effects once the drug has had time to work

为什么是这个答案

The effect of analgesia should be reassessed when it is expected to work, with side effects such as sedation and breathing checked. The result is documented and the plan adjusted.

答案

C · Reassess the pain and any side effects once the drug has had time to work
8.临床护理

答案: D · Tumour lysis syndrome

为什么是这个答案

Rapid tumour cell death releases potassium, phosphate and nucleic acids (forming uric acid), which can cause AKI and arrhythmias. Prevention includes IV hydration and drugs to lower uric acid.

答案

D · Tumour lysis syndrome
9.内外科护理：心血管与呼吸

答案: C · Use the reliever inhaler shortly before exercise and warm up

为什么是这个答案

A short-acting bronchodilator taken shortly before exercise, a gradual warm-up and covering the mouth in cold air help prevent symptoms. Frequent exercise symptoms may mean asthma is poorly controlled and preventer treatment needs review.

答案

C · Use the reliever inhaler shortly before exercise and warm up
10.内外科护理：心血管与呼吸

答案: A · 急性重度哮喘

为什么是这个答案

在常用指南（如 BTS/SIGN）中，峰流速为最佳值的 33–50%、呼吸频率 25 次/分或以上、心率 110 次/分或以上，或不能说完整句子，提示急性重度哮喘。危及生命的特征包括峰流速低于 33%、SpO₂ 低于 92%、“沉默肺”、发绀、衰竭或意识混乱；濒死性哮喘是指 PaCO₂ 升高或需要通气。

答案

A · 急性重度哮喘
11.内外科护理：神经、内分泌与肾脏

答案: D · Acute pancreatitis

为什么是这个答案

GLP-1 receptor agonists have been linked to acute pancreatitis. Severe persistent abdominal pain radiating to the back needs urgent assessment, and the drug is stopped if pancreatitis is suspected.

答案

D · Acute pancreatitis
12.内外科护理：神经、内分泌与肾脏

答案: D · Give IV antibiotics at once and start sepsis treatment

为什么是这个答案

Meningococcal septicaemia can kill within hours. Antibiotics must not be delayed for a lumbar puncture or scan. Fluids and other sepsis care are started, and a lumbar puncture is often unsafe in a shocked patient.

答案

D · Give IV antibiotics at once and start sepsis treatment
13.内外科护理：消化、围手术期与肿瘤

答案: C · Left lower abdominal pain, fever and a raised CRP

为什么是这个答案

Diverticulitis usually causes left iliac fossa pain and tenderness with fever, raised inflammatory markers and a change in bowel habit. CT confirms the diagnosis and shows complications such as abscess.

答案

C · Left lower abdominal pain, fever and a raised CRP
14.内外科护理：消化、围手术期与肿瘤

答案: B · 报告出血；由团队在心脏科的参与下决定，权衡出血与支架血栓

为什么是这个答案

冠状动脉支架置入后早期，停用双联抗血小板治疗有很高的支架血栓和心肌梗死风险，而继续使用则增加出血。决定由医疗团队作出，最好有心脏科和消化科参与；常继续阿司匹林，第二种药物则根据出血严重程度和内镜所见短暂暂停或继续使用。

答案

B · 报告出血；由团队在心脏科的参与下决定，权衡出血与支架血栓

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