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。

新题目返回课程

在打印窗口中选择“另存为 PDF”，即可在设备上保存一份副本。

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

一名成年患者在活动室进食时，突然双手抓住喉咙，无法说话、呼吸或咳嗽。护士应首先做什么？

  1. A给患者一杯水把食物冲下去
  2. B呼救，并进行拍背和腹部冲击
  3. C盲目用手指在口中掏取
  4. D等着看患者能否咳出来
2.优先排序与委派困难

A dehydrated child is to receive IV fluids with added potassium. Which finding should the nurse confirm first?

  1. AThat the child’s temperature is normal
  2. BThat the child is hungry
  3. CThat the child is passing urine
  4. DThat the child can walk without help
3.感染控制与患者安全中等

在给一片药之前，患者说：“这片药和我平时吃的不一样。”护士应怎么做？

  1. A暂停并重新核对医嘱和药物，然后再给药
  2. B告诉患者医院里的药片看起来都不一样
  3. C给半片药并观察有无异常反应
  4. D安慰患者并给药
4.感染控制与患者安全困难

Which patient with a suspected infection meets the qSOFA criteria that signal a higher risk of a poor outcome?

  1. ARespiratory rate 20/min, alert, systolic BP 110 mmHg, heart rate 110/min
  2. BRespiratory rate 24/min, new confusion, systolic BP 95 mmHg
  3. CRespiratory rate 18/min, alert, systolic BP 130 mmHg, temperature 38.5 °C
  4. DRespiratory rate 16/min, alert, systolic BP 105 mmHg, WBC 13,000/mm3
5.实验室检查值与电解质中等

Two sets of blood cultures are ordered for a patient with suspected sepsis. How are they best collected?

  1. AFrom the existing IV line while the infusion continues to run
  2. BBoth from the same site, one minute apart, to save time for the patient
  3. CAfter the first antibiotic dose, so the infusion is not delayed
  4. DFrom two separate venipuncture sites, using strict aseptic technique
6.实验室检查值与电解质困难

A child with sickle cell disease and a recent viral illness is pale and tired. The hemoglobin has fallen sharply, and the reticulocyte count is very low. What is the most likely problem?

  1. AA vaso-occlusive pain crisis in the bones
  2. BA normal finding in sickle cell disease
  3. CAn aplastic crisis, often caused by parvovirus B19
  4. DIron deficiency from a poor diet over months
7.临床护理中等

Which advice is correct for a patient taking levothyroxine?

  1. ATake it with a large meal to avoid nausea and stomach upset
  2. BTake it on an empty stomach, usually before breakfast
  3. CTake it only on days when feeling tired
  4. DStop taking it once the symptoms improve
8.临床护理困难

A nurse teaches a patient with diabetes about foot care. Which statement shows a need for further teaching?

  1. A"I will wear well-fitting shoes."
  2. B"I will see the podiatrist about hard skin."
  3. C"I will walk barefoot at home to toughen my feet."
  4. D"I will check my feet every day for cuts or blisters."
9.内外科护理：心血管与呼吸中等

A peripheral cannula site is red, warm, tender and swollen along the vein. What should the nurse do?

  1. ACover the site and keep using it until it blocks
  2. BFlush the cannula hard to clear it
  3. CLeave it in place, as this is normal after 24 hours
  4. DRemove the cannula, document and monitor the site
10.内外科护理：心血管与呼吸困难

为什么高流量氧疗要使用湿化？

  1. A湿化的气体每升携带的氧气比干燥气体多
  2. B水蒸气可滤除氧气供应中的细菌
  3. C高流量的干燥气体会使气道干燥，分泌物变稠
  4. D湿化可防止氧中毒的发生
11.内外科护理：神经、内分泌与肾脏中等

卒中静脉溶栓前，通常采用哪个血压限值？

  1. A没有血压限值
  2. B低于约 185/110 mmHg
  3. C低于约 90/60 mmHg
  4. D高于约 200/120 mmHg
12.内外科护理：神经、内分泌与肾脏困难

一名老年 2 型糖尿病患者血糖 48 mmol/L，渗透压 365 mOsm/kg，无明显酮体，意识混乱。首要任务是什么？

  1. A大剂量静脉推注胰岛素，使血糖在一小时内降至正常
  2. B谨慎静脉补液，并密切检查渗透压、血钠和血糖
  3. C口服葡萄糖以防治疗期间发生低血糖
  4. D严格限制液体以避免脑水肿
13.内外科护理：消化、围手术期与肿瘤中等

Which diet is usually recommended for a patient with cirrhosis and hepatic encephalopathy?

  1. AOnly clear fluids for several weeks
  2. BA very low-protein diet for the rest of their life to lower ammonia
  3. CNo food at all until the confusion settles
  4. DNormal protein and enough calories, with a late-evening snack
14.内外科护理：消化、围手术期与肿瘤困难

A competent adult who is a Jehovah's Witness refuses blood transfusion before major surgery. What should the nurse do?

  1. AAsk the family to override the decision
  2. BPlan to transfuse secretly during the operation if it becomes needed
  3. CRespect the decision, document it and inform the team
  4. DCancel the surgery without discussing it

3溶液

1.优先排序与委派

答案: B · 呼救，并进行拍背和腹部冲击

为什么是这个答案

不能说话、呼吸或咳嗽的成人存在严重的气道梗阻。欧洲复苏委员会等复苏指南建议拍背最多 5 次，然后腹部冲击最多 5 次，重复直至异物排出；有些指南则从腹部冲击开始。如果患者失去反应，则开始心肺复苏。盲目用手指掏取可能把异物推得更深。

答案

B · 呼救，并进行拍背和腹部冲击
2.优先排序与委派

答案: C · That the child is passing urine

为什么是这个答案

Potassium is not added to IV fluids until the child is passing urine, because poor kidney function can let potassium build up to dangerous levels.

答案

C · That the child is passing urine
3.感染控制与患者安全

答案: A · 暂停并重新核对医嘱和药物，然后再给药

为什么是这个答案

患者的疑虑是一次安全检查。护士应暂停并核对医嘱、药物、剂量和患者，必要时联系药房。有时原因是品牌不同，但必须先加以确认。

答案

A · 暂停并重新核对医嘱和药物，然后再给药
4.感染控制与患者安全

答案: B · Respiratory rate 24/min, new confusion, systolic BP 95 mmHg

为什么是这个答案

qSOFA scores one point each for a respiratory rate of 22/min or more, altered mental status and a systolic BP of 100 mmHg or less. Two or more points mean higher risk, so the first patient needs urgent escalation.

答案

B · Respiratory rate 24/min, new confusion, systolic BP 95 mmHg
5.实验室检查值与电解质

答案: D · From two separate venipuncture sites, using strict aseptic technique

为什么是这个答案

Taking cultures from two separate sites helps distinguish true bacteremia (growth in both sets) from skin contamination (growth in only one). The skin is cleaned carefully, the bottle tops are disinfected, and cultures are taken before antibiotics.

答案

D · From two separate venipuncture sites, using strict aseptic technique
6.实验室检查值与电解质

答案: C · An aplastic crisis, often caused by parvovirus B19

为什么是这个答案

Patients with sickle cell disease depend on a high reticulocyte count because their red cells live only a short time. Parvovirus B19 can stop red cell production for days, causing a rapid fall in hemoglobin with very low reticulocytes. Transfusion may be needed.核对依据: Reticulocyte Count · MedlinePlus (NIH) (2024)

答案

C · An aplastic crisis, often caused by parvovirus B19
7.临床护理

答案: B · Take it on an empty stomach, usually before breakfast

为什么是这个答案

Levothyroxine is absorbed best on an empty stomach and is usually taken at the same time each morning. It is normally lifelong, with doses adjusted by thyroid blood tests.

答案

B · Take it on an empty stomach, usually before breakfast
8.临床护理

答案: C · "I will walk barefoot at home to toughen my feet."

为什么是这个答案

Diabetic neuropathy and poor circulation mean small injuries can become ulcers. Patients should avoid walking barefoot, inspect their feet daily and get professional foot care.

答案

C · "I will walk barefoot at home to toughen my feet."
9.内外科护理：心血管与呼吸

答案: D · Remove the cannula, document and monitor the site

为什么是这个答案

Redness, pain, warmth and swelling along the vein indicate phlebitis. The cannula is removed, the site is observed for infection and the event is documented. Regular visual phlebitis scoring and removing cannulas that are no longer needed reduce the risk.

答案

D · Remove the cannula, document and monitor the site
10.内外科护理：心血管与呼吸

答案: C · 高流量的干燥气体会使气道干燥，分泌物变稠

为什么是这个答案

高流量干燥气体超出了鼻腔湿化的能力，导致黏膜干燥、分泌物变稠和不适。加温加湿的高流量系统可提高耐受性并帮助清除分泌物。

答案

C · 高流量的干燥气体会使气道干燥，分泌物变稠
11.内外科护理：神经、内分泌与肾脏

答案: B · 低于约 185/110 mmHg

为什么是这个答案

许多指南要求溶栓前血压低于 185/110 mmHg，溶栓后 24 小时内低于 180/105 mmHg，因为血压过高会增加出血性转化的风险。读数更高时应先谨慎降压。

答案

B · 低于约 185/110 mmHg
12.内外科护理：神经、内分泌与肾脏

答案: B · 谨慎静脉补液，并密切检查渗透压、血钠和血糖

为什么是这个答案

HHS 首先用静脉补液治疗，单靠补液往往就能降低血糖。渗透压迅速下降有脑水肿风险，所以要逐渐降低。如果有酮体，或补液后血糖不再下降，则以低速率加用胰岛素。由于血栓风险高，VTE 预防很重要。

答案

B · 谨慎静脉补液，并密切检查渗透压、血钠和血糖
13.内外科护理：消化、围手术期与肿瘤

答案: D · Normal protein and enough calories, with a late-evening snack

为什么是这个答案

Protein restriction worsens malnutrition and muscle loss and is no longer routinely advised. Adequate protein and energy, small frequent meals and a late-evening snack are recommended.

答案

D · Normal protein and enough calories, with a late-evening snack
14.内外科护理：消化、围手术期与肿瘤

答案: C · Respect the decision, document it and inform the team

为什么是这个答案

An informed refusal by a competent adult must be respected. The team discusses which products and alternatives (such as cell salvage or iron) the patient accepts, documents the decision and plans to reduce blood loss.

答案

C · Respect the decision, document it and inform the team

本内容为独立练习材料。ExamProblems 与该考试的主办机构没有隶属关系，也未获其认可，考试名称仅用于描述内容。 NCLEX®, NCLEX-RN® and NCLEX-PN® 是 the National Council of State Boards of Nursing, Inc. (NCSBN) 的商标，该机构与 ExamProblems 无关，不为其背书，也不保证其准确性。

ExamProblems · examproblems.com/courses/nclex-style-prioritization-and-delegation