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 called the rapid response team for a deteriorating patient. What should the nurse do while waiting for the team?

  1. AStay with the patient, give oxygen as prescribed and have recent vital signs ready
  2. BGive a dose of every as-needed medication on the chart
  3. CGo to the station to finish documentation for other patients
  4. DLeave the patient for a few minutes to find the relatives and explain what is happening
2.优先排序与委派困难

A patient with COPD on 2 L/min oxygen becomes drowsy and hard to wake. The SpO₂ is 93%. What is the priority?

  1. AIncrease the oxygen to 6 L/min so that the saturation goes even higher than now
  2. BGive the as-needed sedative so the patient rests comfortably
  3. CAssess breathing and escalate for a blood gas, as carbon dioxide may be rising
  4. DLet the patient sleep, because the saturation is above target
3.感染控制与患者安全中等

哪种敷料废弃物应丢入医疗（生物危害）废物？

  1. A无菌敷料包的外层纸包装
  2. B擦手用的干净纸巾
  3. C已过期但未开封的敷料
  4. D被感染伤口渗液浸湿的敷料
4.感染控制与患者安全困难

一名水痘患儿入院。由哪位工作人员护理该患儿最合适？

  1. A怀孕且不确定自己是否有免疫力的护士
  2. B有书面记录证明对水痘有免疫力的护士
  3. C免疫状况不明的实习护生
  4. D从未患过水痘也未接种过疫苗的护士
5.实验室检查值与电解质中等

A pregnant woman's blood type is O Rh-negative, and her antibody screen (indirect Coombs test) is negative. What is usually offered at about 28 weeks?

  1. ADaily oral iron and folic acid supplements only
  2. BAn IV dose of vitamin K given for the fetus
  3. CAnti-D immunoglobulin (Rho(D) immune globulin)
  4. DA transfusion of group O Rh-positive red cells
6.实验室检查值与电解质困难

The nurse teaches a patient with iron-deficiency anemia who is starting oral iron. Which statement shows a need for further teaching?

  1. A"I can take it with orange juice to help absorption"
  2. B"My stools may look darker while I take the tablets"
  3. C"I'll take my iron tablet with a big glass of milk"
  4. D"I'll keep the tablets out of reach of the children"
7.临床护理中等

Which blood results are typical of Addison's disease (primary adrenal insufficiency)?

  1. ALow haemoglobin and high platelets
  2. BHigh sodium and low potassium
  3. CLow sodium and high potassium
  4. DHigh glucose and high calcium
8.临床护理困难

A patient has a blood pressure of 220/130 mmHg with headache, confusion and visual disturbance. Why is the blood pressure lowered in a controlled way rather than as fast as possible?

  1. AA sudden drop can reduce blood flow to the brain, heart and kidneys
  2. BRapid lowering always causes the hypertension to come back much worse
  3. CBlood pressure cannot be lowered with drugs
  4. DRapid lowering causes hyperglycaemia
9.内外科护理：心血管与呼吸中等

A young patient with hypertrophic cardiomyopathy asks why they are told to avoid dehydration. What is the best explanation?

  1. ADehydration makes the heart muscle grow thicker within a few hours
  2. BFluids dissolve the extra muscle in the heart wall
  3. CLow blood volume can worsen obstruction of blood leaving the heart
  4. DDehydration is the cause of the inherited condition
10.内外科护理：心血管与呼吸困难

On day 2 after a surgical tracheostomy, the tube falls out. The patient is breathing but distressed. What should the nurse do first?

  1. ACover the stoma completely with a sealed dressing and wait for help
  2. BLeave the patient alone while fetching a new tube
  3. CForce the tube back through the stoma immediately with firm pressure
  4. DCall for expert help and give oxygen to both the face and the stoma
11.内外科护理：神经、内分泌与肾脏中等

A patient has had a calcium oxalate kidney stone. Which advice best helps prevent another?

  1. ACut all calcium out of the diet
  2. BDrink only a little to avoid diluting the urine
  3. CDrink plenty of fluid so the urine stays pale
  4. DTake extra vitamin C supplements
12.内外科护理：神经、内分泌与肾脏困难

Graves 病患者术后体温 39.8 °C，心率 160 次/分，躁动并呕吐。哪一组治疗最恰当？

  1. A降温、β 受体阻滞剂、抗甲状腺药物，然后用碘和类固醇
  2. B限制液体和使用袢利尿剂治疗心动过速
  3. C用阿司匹林退热，一周内由全科医生复诊
  4. D左甲状腺素和保暖毯，以缓解寒战
13.内外科护理：消化、围手术期与肿瘤中等

Which is a common side effect of opioids, especially when given by epidural or spinal route?

  1. ARinging in the ears
  2. BIncreased hunger
  3. CHair growth
  4. DItching
14.内外科护理：消化、围手术期与肿瘤困难

A patient with a PICC line develops swelling and aching of the same arm and prominent veins on the chest. What should the nurse suspect?

  1. ANormal swelling after line insertion
  2. BAn allergy to the dressing
  3. CLymphoedema from a previous operation
  4. DA catheter-related deep vein thrombosis

3溶液

1.优先排序与委派

答案: A · Stay with the patient, give oxygen as prescribed and have recent vital signs ready

为什么是这个答案

The nurse stays with the patient, starts basic support such as oxygen as prescribed and prepares a clear handover. Leaving the patient or giving unrelated medications is unsafe.

答案

A · Stay with the patient, give oxygen as prescribed and have recent vital signs ready
2.优先排序与委派

答案: C · Assess breathing and escalate for a blood gas, as carbon dioxide may be rising

为什么是这个答案

In COPD, drowsiness can be a sign of carbon dioxide retention (hypercapnia), even when the saturation is acceptable. The nurse assesses breathing, escalates and avoids extra oxygen or sedatives that could worsen it.

答案

C · Assess breathing and escalate for a blood gas, as carbon dioxide may be rising
3.感染控制与患者安全

答案: D · 被感染伤口渗液浸湿的敷料

为什么是这个答案

被血液或感染性体液污染的物品应依当地规定放入医疗废物。干净的包装放入一般废物或可回收垃圾，使医疗废物量尽可能少。

答案

D · 被感染伤口渗液浸湿的敷料
4.感染控制与患者安全

答案: B · 有书面记录证明对水痘有免疫力的护士

为什么是这个答案

应由免疫状况确凿（来自接种疫苗或既往感染）的工作人员护理水痘患者。无免疫力的工作人员，尤其是孕期工作人员，有感染风险，并可能把病毒传给其他患者。

答案

B · 有书面记录证明对水痘有免疫力的护士
5.实验室检查值与电解质

答案: C · Anti-D immunoglobulin (Rho(D) immune globulin)

为什么是这个答案

An Rh-negative mother can form anti-D antibodies if Rh-positive fetal blood enters her circulation, which can cause hemolytic disease in a later pregnancy. Anti-D immunoglobulin at about 28 weeks and after delivery of an Rh-positive baby prevents this sensitization.核对依据: Red Blood Cell Antibody Screen · MedlinePlus (NIH) (2025); Hemolytic disease of the newborn · MedlinePlus (NIH) (2025)

答案

C · Anti-D immunoglobulin (Rho(D) immune globulin)
6.实验室检查值与电解质

答案: C · "I'll take my iron tablet with a big glass of milk"

为什么是这个答案

Calcium in milk, as well as antacids and tea, reduces iron absorption, so iron should not be taken with them. Vitamin C improves absorption, dark stools are expected, and iron overdose is a serious poisoning risk in young children.核对依据: Iron deficiency anemia - Medical Encyclopedia · MedlinePlus (NIH) (2025); Iron in diet - Medical Encyclopedia · MedlinePlus (NIH) (2025)

答案

C · "I'll take my iron tablet with a big glass of milk"
7.临床护理

答案: C · Low sodium and high potassium

为什么是这个答案

Without aldosterone, the kidneys lose sodium and retain potassium. Patients may also have low blood pressure, low glucose and increased skin pigmentation.

答案

C · Low sodium and high potassium
8.临床护理

答案: A · A sudden drop can reduce blood flow to the brain, heart and kidneys

为什么是这个答案

In a hypertensive emergency, autoregulation in vital organs is reset to higher pressures. Lowering BP too fast can cause ischaemia, so it is reduced gradually under close monitoring.

答案

A · A sudden drop can reduce blood flow to the brain, heart and kidneys
9.内外科护理：心血管与呼吸

答案: C · Low blood volume can worsen obstruction of blood leaving the heart

为什么是这个答案

In hypertrophic cardiomyopathy, a thickened septum can obstruct the left ventricular outflow tract, and the obstruction worsens when the ventricle is underfilled. Dehydration, vasodilators and strenuous exertion can trigger symptoms or arrhythmias. It is a cause of sudden cardiac death in young people.

答案

C · Low blood volume can worsen obstruction of blood leaving the heart
10.内外科护理：心血管与呼吸

答案: D · Call for expert help and give oxygen to both the face and the stoma

为什么是这个答案

In the first days after a tracheostomy, the tract is immature and the tube can easily be misplaced into the tissues. Emergency guidance is to call for an airway expert, apply oxygen to face and stoma and assess breathing. Reinsertion is done only by trained staff.

答案

D · Call for expert help and give oxygen to both the face and the stoma
11.内外科护理：神经、内分泌与肾脏

答案: C · Drink plenty of fluid so the urine stays pale

为什么是这个答案

High fluid intake is the most important measure for preventing stones. Dietary calcium is usually not restricted, because it binds oxalate in the gut. High-dose vitamin C can increase oxalate.

答案

C · Drink plenty of fluid so the urine stays pale
12.内外科护理：神经、内分泌与肾脏

答案: A · 降温、β 受体阻滞剂、抗甲状腺药物，然后用碘和类固醇

为什么是这个答案

甲状腺危象危及生命。治疗包括支持治疗和降温、用 β 受体阻滞剂控制肾上腺素能症状、用硫脲类药物（常为丙硫氧嘧啶）阻断合成、在硫脲类之后给予碘以阻断激素释放，以及皮质类固醇。避免使用阿司匹林，因为它会增加游离甲状腺激素。

答案

A · 降温、β 受体阻滞剂、抗甲状腺药物，然后用碘和类固醇
13.内外科护理：消化、围手术期与肿瘤

答案: D · Itching

为什么是这个答案

Pruritus is common with neuraxial opioids. Other common effects include nausea, urinary retention, constipation and sedation; respiratory depression is the most serious.

答案

D · Itching
14.内外科护理：消化、围手术期与肿瘤

答案: D · A catheter-related deep vein thrombosis

为什么是这个答案

PICCs increase the risk of upper limb DVT. Arm swelling, pain and dilated superficial veins are reported for ultrasound assessment and possible anticoagulation; the line is not used until reviewed.

答案

D · A catheter-related deep vein thrombosis

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