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

A patient receives hemodialysis this morning. Which type of medication is often held before dialysis, as prescribed?

  1. AEye drops for glaucoma
  2. BAntihypertensive drugs
  3. CInhaled bronchodilators
  4. DTopical skin creams
2.优先排序与委派困难

After handover on a medical unit, which patient should the nurse see first?

  1. ADeep vein thrombosis on a heparin infusion, aPTT in the target range
  2. BPneumonia on 2 L/min oxygen, SpO₂ 93%, talking in full sentences
  3. CDay 2 after a hernia repair, pain 6/10, oral analgesic due in 20 minutes, wants it now
  4. DNew atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy
3.感染控制与患者安全中等

A patient has received oral radioactive iodine therapy. Which precaution is usually taken?

  1. ALet the patient share a bathroom with other patients
  2. BEncourage pregnant visitors to sit close to the patient to give emotional support
  3. CPlace the patient on droplet precautions with a surgical mask
  4. DLimit time close to the patient and handle body fluids per radiation policy
4.感染控制与患者安全困难

A patient was harmed by a medication error and asks the nurse what happened. Which approach is best?

  1. ATell the patient to make a formal complaint to find out
  2. BBe honest that an error occurred and involve the provider and team in disclosure per policy
  3. CTell the patient nothing happened to avoid worry
  4. DBlame the pharmacy for the error so that the nurse and the ward are not at fault
5.实验室检查值与电解质中等

When blood is drawn from a central venous catheter, why is a small volume of blood usually discarded first, according to policy?

  1. ATo check that the catheter tip is still in the right vein
  2. BTo remove blood clots that form in all central lines
  3. CTo avoid diluting the sample with flush or infusion fluid
  4. DTo lower the patient's hemoglobin for a blood transfusion
6.实验室检查值与电解质困难

A patient with long-term heavy alcohol use is admitted with alcohol withdrawal. Which group of electrolyte problems is most common?

  1. AHigh sodium, high calcium and high glucose
  2. BHigh magnesium, high phosphate and high potassium
  3. CLow chloride, high bicarbonate and high calcium
  4. DLow magnesium, low phosphate and low potassium
7.临床护理中等

A patient on peritoneal dialysis notices the drained fluid has become cloudy and has abdominal pain. What is likely?

  1. APeritonitis
  2. BConstipation
  3. CNormal dialysis fluid
  4. DA urinary tract infection
8.临床护理困难

A patient with long-standing COPD has an arterial blood gas with pH 7.37, a raised PaCO2 and a raised bicarbonate. How is this best described?

  1. ACompensated respiratory acidosis
  2. BMixed metabolic and respiratory alkalosis
  3. CUncompensated metabolic alkalosis
  4. DAcute respiratory acidosis
9.内外科护理：心血管与呼吸中等

A patient with bronchiectasis of the right lower lobe is taught postural drainage. How should they be positioned?

  1. ASitting fully upright at all times
  2. BWith the affected lobe uppermost so gravity drains it
  3. CFlat on the back with the arms raised
  4. DWith the affected lobe lowest so it fills with mucus
10.内外科护理：心血管与呼吸困难

An older patient with three rib fractures is breathing shallowly and refuses to cough because of pain. What is the priority intervention?

  1. AStrap the chest tightly with bandages to stop the ribs moving
  2. BKeep the patient flat and still in bed until the pain settles
  3. CWithhold analgesia to avoid depressing breathing
  4. DEffective analgesia so they can breathe deeply and cough
11.内外科护理：神经、内分泌与肾脏中等

一名患者卒中后出现同向性偏盲。护士起初应如何帮助？

  1. A用眼罩遮盖患侧的眼睛
  2. B从看得见的一侧接近，并教其转头扫视
  3. C把呼叫铃和饮品放在看不见的一侧以训练该侧
  4. D保持房间昏暗以减少视觉刺激
12.内外科护理：神经、内分泌与肾脏困难

A patient had a witnessed tonic-clonic seizure. Afterwards their left arm is weak, and the weakness improves over the next few hours. What is the best interpretation?

  1. AA sign that the patient is pretending to be weak
  2. BCertainly a stroke, so the seizure can be ignored
  3. CPossible postictal (Todd's) paresis, but a stroke must still be excluded
  4. DNormal postictal tiredness that needs no further assessment or imaging at all
13.内外科护理：消化、围手术期与肿瘤中等

Which infection control measure is correct for a patient with C. difficile diarrhoea?

  1. AA face mask for the patient and visitors only
  2. BA single room with its own toilet, and soap-and-water handwashing
  3. CA shared bay, as long as alcohol gel is used after every contact
  4. DNo special measures once antibiotics have started
14.内外科护理：消化、围手术期与肿瘤困难

A patient with recurrent diverticulitis reports passing air and faecal matter in the urine. What is the most likely cause?

  1. AA kidney stone blocking the ureter
  2. BA fistula between the colon and the bladder
  3. CBowel preparation that was taken too quickly
  4. DA simple lower urinary tract infection

3溶液

1.优先排序与委派

答案: B · Antihypertensive drugs

为什么是这个答案

Removing fluid during dialysis can cause hypotension, so blood pressure drugs are often held before treatment as prescribed. Some drugs are also removed by dialysis and given afterwards.

答案

B · Antihypertensive drugs
2.优先排序与委派

答案: D · New atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy

为什么是这个答案

Rapid atrial fibrillation with hypotension and dizziness means the heart is not pumping enough blood; the patient is unstable. The other patients are within target or have predictable needs.

答案

D · New atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy
3.感染控制与患者安全

答案: D · Limit time close to the patient and handle body fluids per radiation policy

为什么是这个答案

Radioactive iodine is excreted in urine, sweat and saliva, so the patient is usually in a private room with their own bathroom. Staff limit time near them, use distance and follow policy for body fluids and waste.

答案

D · Limit time close to the patient and handle body fluids per radiation policy
4.感染控制与患者安全

答案: B · Be honest that an error occurred and involve the provider and team in disclosure per policy

为什么是这个答案

Open, honest disclosure of errors is an ethical duty and part of a safety culture. The nurse follows policy, which usually involves the provider and risk team, and does not hide or blame.

答案

B · Be honest that an error occurred and involve the provider and team in disclosure per policy
5.实验室检查值与电解质

答案: C · To avoid diluting the sample with flush or infusion fluid

为什么是这个答案

Central lines contain flush solution or infused fluids, which can dilute the sample or add glucose, heparin or electrolytes. Infusions are paused and an initial volume is discarded (or reinfused per policy) before the sample is drawn; then the line is flushed.

答案

C · To avoid diluting the sample with flush or infusion fluid
6.实验室检查值与电解质

答案: D · Low magnesium, low phosphate and low potassium

为什么是这个答案

Poor diet, vomiting, diarrhea and alcohol's effect on the kidneys commonly cause low magnesium, phosphate and potassium. These worsen arrhythmia and seizure risk, so they are checked and replaced, together with thiamine.

答案

D · Low magnesium, low phosphate and low potassium
7.临床护理

答案: A · Peritonitis

为什么是这个答案

Cloudy effluent with abdominal pain or fever suggests peritonitis, the main serious complication of peritoneal dialysis. The fluid is sent for culture and treatment started promptly.

答案

A · Peritonitis
8.临床护理

答案: A · Compensated respiratory acidosis

为什么是这个答案

Chronic CO2 retention is offset by the kidneys retaining bicarbonate, bringing the pH back to normal. A normal pH with high PaCO2 and high bicarbonate is a compensated respiratory acidosis.

答案

A · Compensated respiratory acidosis
9.内外科护理：心血管与呼吸

答案: B · With the affected lobe uppermost so gravity drains it

为什么是这个答案

Postural drainage places the patient so the affected segment is above the main bronchus, letting gravity move secretions towards the larger airways to be coughed up. It is combined with breathing techniques. Head-down positions are avoided in patients with reflux, recent surgery or breathlessness.

答案

B · With the affected lobe uppermost so gravity drains it
10.内外科护理：心血管与呼吸

答案: D · Effective analgesia so they can breathe deeply and cough

为什么是这个答案

Pain from rib fractures causes shallow breathing and poor coughing, leading to atelectasis and pneumonia, especially in older adults. Good analgesia (sometimes regional blocks), deep breathing, coughing with support and early mobilisation are key. Chest strapping restricts breathing and is not used.

答案

D · Effective analgesia so they can breathe deeply and cough
11.内外科护理：神经、内分泌与肾脏

答案: B · 从看得见的一侧接近，并教其转头扫视

为什么是这个答案

起初，把重要物品放在视力完好的一侧并从该侧接近患者，可提高安全性。随着时间推移，教患者向缺失的视野侧转头扫视。遮盖一只眼没有帮助，因为双眼丢失的是同一半视野。

答案

B · 从看得见的一侧接近，并教其转头扫视
12.内外科护理：神经、内分泌与肾脏

答案: C · Possible postictal (Todd's) paresis, but a stroke must still be excluded

为什么是这个答案

Todd's paresis is a temporary weakness after a seizure that usually resolves within hours to a couple of days. Because a stroke can cause seizures and look the same, the patient still needs a full assessment and usually imaging.

答案

C · Possible postictal (Todd's) paresis, but a stroke must still be excluded
13.内外科护理：消化、围手术期与肿瘤

答案: B · A single room with its own toilet, and soap-and-water handwashing

为什么是这个答案

C. difficile forms spores that resist alcohol gel, so soap and water are used. Patients are isolated with their own toilet, staff use gloves and aprons, and the environment is cleaned with a sporicidal agent such as chlorine.

答案

B · A single room with its own toilet, and soap-and-water handwashing
14.内外科护理：消化、围手术期与肿瘤

答案: B · A fistula between the colon and the bladder

为什么是这个答案

Pneumaturia and faecaluria suggest a colovesical fistula, a recognised complication of diverticulitis (and Crohn's disease or cancer). Recurrent urinary infections are common, and surgery is usually needed.

答案

B · A fistula between the colon and the bladder

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