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

Which action by a nursing assistant needs the nurse to step in?

  1. ALowering the bed to its lowest position and locking the wheels after care
  2. BTaking an oral temperature just after the patient drank cold water
  3. CPutting the call light within the patient’s reach
  4. DCleaning hands before entering the room
2.优先排序与委派困难

Which finding most suggests a tension pneumothorax rather than a simple pneumothorax?

  1. AMild breathlessness with reduced breath sounds on one side of the chest only
  2. BA small air leak seen on a routine chest X-ray
  3. CTrachea shifted away from the affected side, with low blood pressure
  4. DSharp chest pain that is worse on deep breathing
3.感染控制与患者安全中等

A patient wants to use their own electric hair dryer in the hospital. What is correct?

  1. AIt can be plugged into an extension lead under the bed
  2. BIt can be used straight away if it looks new
  3. CIt is checked for electrical safety according to hospital policy before use
  4. DIt can be used in the bathroom near the sink if the patient is careful
4.感染控制与患者安全困难

Patients contaminated with radioactive dust arrive at the hospital. Which step removes most of the external contamination?

  1. AWrapping the patient in a blanket
  2. BRemoving the patient’s clothing
  3. CGiving the patient potassium iodide
  4. DScrubbing the skin until it is red
5.实验室检查值与电解质中等

A patient has weight loss, tremor and heat intolerance. Which thyroid test pattern fits Graves disease?

  1. AHigh TSH with a normal free T4
  2. BNormal TSH with a low free T4
  3. CLow TSH with a high free T4
  4. DHigh TSH with a low free T4
6.实验室检查值与电解质困难

A patient without symptoms has a finger-stick glucose of 340 mg/dL (18.9 mmol/L). The previous values were normal, and the patient has just peeled an orange. What should the nurse do first?

  1. AAsk the laboratory to measure HbA1c from the same drop of blood
  2. BReport the result as a new diagnosis of diabetes mellitus
  3. CGive a correction dose of insulin for a glucose of 340 mg/dL
  4. DHave the patient wash and dry their hands, then repeat the test
7.临床护理中等

Which examination findings suggest a large pleural effusion on one side?

  1. AA hyper-resonant chest with the trachea pulled towards that side
  2. BNormal breath sounds and normal percussion
  3. CWheeze heard over both lungs
  4. DDull percussion and reduced breath sounds over the lung base
8.临床护理困难

A patient is recognised by the team as being in the last days of life. Which approach is correct?

  1. AContinue all routine blood tests and observations four-hourly
  2. BStop all medicines, including pain relief and anti-sickness drugs
  3. CReview and stop treatments that no longer help, and focus on comfort
  4. DAvoid talking with the family about what is happening
9.内外科护理：心血管与呼吸中等

What is the purpose of a mucolytic such as carbocisteine in chronic productive cough?

  1. ATo widen the airways within minutes
  2. BTo make sputum thinner and easier to cough up
  3. CTo kill bacteria in the airways
  4. DTo stop the patient coughing completely, day and night
10.内外科护理：心血管与呼吸困难

On a ventilated patient, the end-tidal CO₂ waveform suddenly drops to zero. What should the nurse suspect first?

  1. ATube displacement, disconnection or obstruction
  2. BNormal variation that needs no action
  3. CA sudden improvement in the patient's lung function
  4. DA rise in the patient's body temperature over the last hour
11.内外科护理：神经、内分泌与肾脏中等

A patient on peritoneal dialysis has gained weight and has higher glucose levels. Which part of the treatment is the likely cause?

  1. AProtein lost into the dialysis fluid
  2. BAir entering the abdomen during exchanges
  3. CGlucose absorbed from the dialysis fluid
  4. DSodium lost into the dialysis fluid
12.内外科护理：神经、内分泌与肾脏困难

A patient with diabetic neuropathy has a hot, red, swollen foot that is barely painful. The skin is intact, and there is no fever. What should the nurse suspect?

  1. AGout, which only needs pain relief
  2. BA sprained ankle that will settle with walking
  3. CAn acute Charcot foot, needing urgent offloading
  4. DNormal swelling from standing too long
13.内外科护理：消化、围手术期与肿瘤中等

Which advice helps a patient with haemorrhoids?

  1. ATake a codeine-based painkiller every day
  2. BEat less fibre so that stools are smaller
  3. CEat more fibre, drink enough fluid and avoid straining
  4. DSit on the toilet for long periods to empty fully
14.内外科护理：消化、围手术期与肿瘤困难

A dying patient has noisy, rattling breathing. The patient seems unaware, but the family is distressed. What is the best nursing approach?

  1. APerform deep suction every hour
  2. BReposition, explain the cause and give prescribed drugs if needed
  3. CGive large volumes of IV fluid to loosen and thin the secretions
  4. DAsk the family to leave the room

3溶液

1.优先排序与委派

答案: B · Taking an oral temperature just after the patient drank cold water

为什么是这个答案

A cold drink lowers mouth temperature for a short time, so the reading will be falsely low. The nurse should ask the assistant to wait before measuring. The other actions are correct.

答案

B · Taking an oral temperature just after the patient drank cold water
2.优先排序与委派

答案: C · Trachea shifted away from the affected side, with low blood pressure

为什么是这个答案

In tension pneumothorax, trapped air pushes the mediastinum to the other side, reducing venous return and blood pressure. It is life-threatening and needs immediate decompression.

答案

C · Trachea shifted away from the affected side, with low blood pressure
3.感染控制与患者安全

答案: C · It is checked for electrical safety according to hospital policy before use

为什么是这个答案

Electrical items from home can be faulty and cause shocks or fires. Policies usually require them to be inspected before use, and extension cords near patients are avoided.

答案

C · It is checked for electrical safety according to hospital policy before use
4.感染控制与患者安全

答案: B · Removing the patient’s clothing

为什么是这个答案

Removing clothing, then gently washing the skin, gets rid of most external radioactive contamination. Hard scrubbing damages the skin, and potassium iodide only protects the thyroid from radioactive iodine.

答案

B · Removing the patient’s clothing
5.实验室检查值与电解质

答案: C · Low TSH with a high free T4

为什么是这个答案

In Graves disease, antibodies stimulate the thyroid to make too much hormone. The high free T4 suppresses TSH from the pituitary through negative feedback, so TSH is low. A high TSH with a low T4 fits primary hypothyroidism.核对依据: TSH test · MedlinePlus (NIH) (2026); Thyroxine (T4) Test · MedlinePlus (NIH) (2024); Graves disease · MedlinePlus (NIH) (2026)

答案

C · Low TSH with a high free T4
6.实验室检查值与电解质

答案: D · Have the patient wash and dry their hands, then repeat the test

为什么是这个答案

Sugar residue on the fingers can give a falsely high finger-stick result. The hands are washed with soap and water and dried, and the test repeated. If the value is still high, it is confirmed and reported. Treating a false result could cause hypoglycemia.

答案

D · Have the patient wash and dry their hands, then repeat the test
7.临床护理

答案: D · Dull percussion and reduced breath sounds over the lung base

为什么是这个答案

Fluid in the pleural space muffles breath sounds and makes percussion stony dull. A large effusion may push the trachea away from the affected side.

答案

D · Dull percussion and reduced breath sounds over the lung base
8.临床护理

答案: C · Review and stop treatments that no longer help, and focus on comfort

为什么是这个答案

When dying is recognised, non-beneficial interventions are stopped and anticipatory medicines for symptoms such as pain, agitation and secretions are prescribed. Clear communication with the patient and family is essential.

答案

C · Review and stop treatments that no longer help, and focus on comfort
9.内外科护理：心血管与呼吸

答案: B · To make sputum thinner and easier to cough up

为什么是这个答案

Mucolytics reduce sputum viscosity, which can make expectoration easier and may reduce exacerbations in some people with COPD. They are not bronchodilators or antibiotics. Cough suppressants are generally avoided in productive cough.

答案

B · To make sputum thinner and easier to cough up
10.内外科护理：心血管与呼吸

答案: A · Tube displacement, disconnection or obstruction

为什么是这个答案

A sudden loss of the capnography trace means no CO₂ is being detected: the tube may be dislodged, disconnected or blocked, or there may be cardiac arrest. The nurse checks the patient and circuit immediately, hand-ventilates if needed and calls for help.

答案

A · Tube displacement, disconnection or obstruction
11.内外科护理：神经、内分泌与肾脏

答案: C · Glucose absorbed from the dialysis fluid

为什么是这个答案

Standard PD fluids contain glucose to pull water out by osmosis. Some glucose is absorbed, adding calories and raising blood glucose. Glucose monitoring and diet advice are needed, and other solutions may be used.

答案

C · Glucose absorbed from the dialysis fluid
12.内外科护理：神经、内分泌与肾脏

答案: C · An acute Charcot foot, needing urgent offloading

为什么是这个答案

Acute Charcot neuroarthropathy causes inflammation and destruction of bones and joints in a foot without protective sensation. It can look like cellulitis. Early immobilisation and offloading prevent permanent deformity.

答案

C · An acute Charcot foot, needing urgent offloading
13.内外科护理：消化、围手术期与肿瘤

答案: C · Eat more fibre, drink enough fluid and avoid straining

为什么是这个答案

Soft stools reduce straining and pressure on the anal cushions. Long sitting on the toilet and constipating drugs such as codeine should be avoided.

答案

C · Eat more fibre, drink enough fluid and avoid straining
14.内外科护理：消化、围手术期与肿瘤

答案: B · Reposition, explain the cause and give prescribed drugs if needed

为什么是这个答案

Noisy respiratory secretions near death come from secretions in the throat that the patient cannot clear. Repositioning, explanation and anticholinergic drugs may help; deep suction is usually distressing and ineffective.

答案

B · Reposition, explain the cause and give prescribed drugs if needed

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