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 nurse has given rapid-acting insulin, and then learns that the patient’s meal tray will be 45 minutes late. What should the nurse do?

  1. ATell the patient to wait and do nothing until the tray comes
  2. BGive a second, smaller dose of insulin when the meal tray finally arrives
  3. CAsk the patient to walk around the ward until the food arrives
  4. DGet the patient some carbohydrate food now and check the glucose
2.优先排序与委派困难

交班后，护士应首先评估哪位患者？

  1. ACOPD，吸氧 2 L/min：SpO₂ 90%，呼吸频率 22 次/分，处于平时的基线
  2. B经股动脉心导管术后 1 小时：新出现背痛，脉搏 118 次/分，血压 92/58 mmHg
  3. C胆囊手术后第 2 天：疼痛 6/10，下一次镇痛药 30 分钟后到期
  4. D2 型糖尿病：午餐前血糖 210 mg/dL（11.7 mmol/L），无症状
3.感染控制与患者安全中等

患者的血液意外溅入护士眼睛后，护士应怎么做？

  1. A先用干净的干纸巾轻轻揉眼睛擦去血液
  2. B立即用大量清水或生理盐水冲洗眼睛，然后上报
  3. C滴抗生素眼药水，不告诉任何人
  4. D完成操作，第二天再上报
4.感染控制与患者安全困难

A patient’s blood splashes onto a nurse’s forearm. The skin is intact. What is the correct response?

  1. AStart HIV post-exposure prophylaxis right away, before any other step is taken
  2. BScrub the area with undiluted bleach
  3. CWash the area with soap and water, then follow the reporting policy
  4. DDo nothing, because intact skin cannot be contaminated
5.实验室检查值与电解质中等

A patient with a potassium of 2.8 mEq/L has potassium chloride prescribed IV. Which statement about giving it is correct?

  1. AIt is given as an undiluted bolus into a large vein to avoid irritation
  2. BIt is always diluted and given by infusion pump, never as an IV push
  3. CIt may be given as a slow IV push over one minute if the level is very low
  4. DIt is added to the IV bag without mixing, so it stays at the bottom
6.实验室检查值与电解质困难

Which patient should the nurse assess first?

  1. AHypertension with a potassium of 3.6 mEq/L on a thiazide
  2. BHeart failure with a BNP lower than the result on admission
  3. CChest pain with troponin rising from the first to the second sample
  4. DStable angina with a total cholesterol of 245 mg/dL (6.3 mmol/L)
7.临床护理中等

Which is a recognised risk factor for postoperative nausea and vomiting?

  1. AA short operation under local anaesthetic
  2. BBeing male
  3. CBeing a smoker
  4. DUse of opioids after surgery
8.临床护理困难

An acutely ill patient without COPD is on 15 L/min oxygen, and their SpO2 is now 100% and stable. What should be done?

  1. AKeep the oxygen at 15 L/min for at least a week to be on the safe side
  2. BIncrease the oxygen further to build up a reserve
  3. CReduce the oxygen to keep the SpO2 within the prescribed target range
  4. DStop the oxygen and the saturation monitoring because the patient is now well
9.内外科护理：心血管与呼吸中等

Suspected pulmonary TB is being investigated. How are sputum samples usually collected?

  1. AOne sample of saliva collected at any time of the day
  2. BA swab from the nose only
  3. CSeveral samples, ideally including early-morning sputum
  4. DA single sample after the first week of treatment
10.内外科护理：心血管与呼吸困难

经桡动脉心导管检查术后，最重要的评估是什么？

  1. A每四小时的尿比重
  2. B检查后每小时的肠鸣音和腹围
  3. C手部的血液循环、感觉和活动，以及穿刺部位
  4. D每 15 分钟的瞳孔大小和对光反应
11.内外科护理：神经、内分泌与肾脏中等

Which statement about storing insulin is correct?

  1. AInsulin should be kept on a sunny windowsill to stay warm
  2. BInsulin that has been frozen can be used once it has thawed
  3. CUnopened insulin goes in the fridge and must never be frozen
  4. DAll insulin must be stored in the freezer to keep it stable
12.内外科护理：神经、内分泌与肾脏困难

Two days after surgery, an 80-year-old woman is quiet, sleepy, slow to answer and eating little. Her daughter says she is "not herself". What should the nurse suspect?

  1. AHypoactive delirium
  2. BThe start of Alzheimer's disease
  3. CNormal tiredness after an operation
  4. DSimple low mood about being in hospital
13.内外科护理：消化、围手术期与肿瘤中等

For which stoma can colostomy irrigation be considered?

  1. AAn ileal conduit draining urine
  2. BA new ileostomy in the first week
  3. CAny stoma that has liquid or very loose output
  4. DAn established descending or sigmoid colostomy
14.内外科护理：消化、围手术期与肿瘤困难

A nurse teaches a carer about overnight tube feeding at home. Which statement shows a need for further teaching?

  1. A"I'll stop the feed and call if he coughs or struggles to breathe."
  2. B"I'll check the external length mark on the tube every day."
  3. C"I'll let him lie flat so he sleeps better while the feed runs."
  4. D"I'll flush the tube with water before and after his medicines."

3溶液

1.优先排序与委派

答案: D · Get the patient some carbohydrate food now and check the glucose

为什么是这个答案

Rapid-acting insulin starts working within minutes, so a long delay before eating risks hypoglycemia. The nurse arranges food or carbohydrate now and monitors the glucose.

答案

D · Get the patient some carbohydrate food now and check the glucose
2.优先排序与委派

答案: B · 经股动脉心导管术后 1 小时：新出现背痛，脉搏 118 次/分，血压 92/58 mmHg

为什么是这个答案

股动脉穿刺后出现背痛、心动过速和低血压，提示腹膜后出血，这种出血可能隐匿而致命。COPD 患者处于基线，疼痛是预期的且正在处理，血糖偏高但不是急症。

答案

B · 经股动脉心导管术后 1 小时：新出现背痛，脉搏 118 次/分，血压 92/58 mmHg
3.感染控制与患者安全

答案: B · 立即用大量清水或生理盐水冲洗眼睛，然后上报

为什么是这个答案

应立即用大量清水或生理盐水冲洗黏膜，例如在洗眼站。暴露应立即上报，以便评估风险并考虑暴露后治疗。

答案

B · 立即用大量清水或生理盐水冲洗眼睛，然后上报
4.感染控制与患者安全

答案: C · Wash the area with soap and water, then follow the reporting policy

为什么是这个答案

Blood on intact skin carries very little risk of bloodborne infection, but it is still washed off promptly and handled according to policy. Bleach damages skin, and prophylaxis is for higher-risk exposures.

答案

C · Wash the area with soap and water, then follow the reporting policy
5.实验室检查值与电解质

答案: B · It is always diluted and given by infusion pump, never as an IV push

为什么是这个答案

Concentrated potassium chloride given as an IV push can cause fatal cardiac arrest, so it is never pushed. It is diluted, mixed well and given by infusion pump at a rate set by protocol, often with cardiac monitoring at higher rates.

答案

B · It is always diluted and given by infusion pump, never as an IV push
6.实验室检查值与电解质

答案: C · Chest pain with troponin rising from the first to the second sample

为什么是这个答案

A rising troponin with chest pain indicates acute myocardial injury, possibly infarction, which needs urgent assessment and treatment. High cholesterol is a long-term risk, a falling BNP shows improvement, and a potassium of 3.6 mEq/L is normal.核对依据: Troponin Test · MedlinePlus (NIH) (2023)

答案

C · Chest pain with troponin rising from the first to the second sample
7.临床护理

答案: D · Use of opioids after surgery

为什么是这个答案

Known risk factors include opioids, female sex, being a non-smoker, previous PONV or motion sickness and longer general anaesthetics. High-risk patients may be given preventive antiemetics.

答案

D · Use of opioids after surgery
8.临床护理

答案: C · Reduce the oxygen to keep the SpO2 within the prescribed target range

为什么是这个答案

Oxygen is prescribed to a target range, usually 94–98% for most patients. Once the patient is stable it should be weaned down, as unnecessary hyperoxia has no benefit and can be harmful.

答案

C · Reduce the oxygen to keep the SpO2 within the prescribed target range
9.内外科护理：心血管与呼吸

答案: C · Several samples, ideally including early-morning sputum

为什么是这个答案

Usually three sputum samples, including an early-morning sample, are sent for smear microscopy, culture and molecular testing. Deep coughed sputum, not saliva, is needed. Samples are collected before treatment where possible and in a way that limits exposure to others.

答案

C · Several samples, ideally including early-morning sputum
10.内外科护理：心血管与呼吸

答案: C · 手部的血液循环、感觉和活动，以及穿刺部位

为什么是这个答案

桡动脉入路后，应检查压迫装置和穿刺部位有无出血或血肿，并检查手部的颜色、温度、毛细血管再充盈、感觉和活动。桡动脉闭塞和前臂骨筋膜室综合征是可能的并发症。

答案

C · 手部的血液循环、感觉和活动，以及穿刺部位
11.内外科护理：神经、内分泌与肾脏

答案: C · Unopened insulin goes in the fridge and must never be frozen

为什么是这个答案

Unopened insulin is kept in a fridge at about 2–8 °C. Freezing or heat destroys it, so frozen insulin must be thrown away. In-use pens can usually be kept at room temperature for the time stated by the manufacturer.

答案

C · Unopened insulin goes in the fridge and must never be frozen
12.内外科护理：神经、内分泌与肾脏

答案: A · Hypoactive delirium

为什么是这个答案

Hypoactive delirium presents with drowsiness, withdrawal and slowness rather than agitation, so it is often missed. It has a worse prognosis than the hyperactive form. A family report of a sudden change is important, and a screening tool such as the 4AT or the CAM (Confusion Assessment Method) can be used.

答案

A · Hypoactive delirium
13.内外科护理：消化、围手术期与肿瘤

答案: D · An established descending or sigmoid colostomy

为什么是这个答案

Irrigation instils water into a sigmoid or descending colostomy to empty the bowel at set times. It is not used for ileostomies or urostomies and needs specialist teaching.

答案

D · An established descending or sigmoid colostomy
14.内外科护理：消化、围手术期与肿瘤

答案: C · "I'll let him lie flat so he sleeps better while the feed runs."

为什么是这个答案

The head should stay raised by at least 30–45° during feeding and for a while afterwards. Flushing, checking the tube length and stopping for breathing problems are all correct.

答案

C · "I'll let him lie flat so he sleeps better while the feed runs."

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