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

四名患者同时到达急诊科。应先看谁？

  1. A一名手臂有伤口、出血已控制的青少年
  2. B一名 2 岁的儿童，流口水，身体前倾，有喘鸣
  3. C一名脚踝畸形但足部脉搏正常的成人
  4. D一名偏头痛、血压 150/90 mmHg 的成人
3.感染控制与患者安全中等

Which patient has the highest risk of a burn from a heating pad?

  1. AA patient with a sprained wrist who is fully alert
  2. BA patient with diabetic peripheral neuropathy
  3. CA patient recovering from a cold
  4. DA healthy young adult with a strained muscle
4.感染控制与患者安全困难

一名干细胞移植后严重免疫抑制的患者住在保护性环境中。下列哪件物品不应带入房间？

  1. A一台干净、已消毒的平板电脑
  2. B一张已擦拭干净的相框全家福
  3. C患者自己的干净衣物
  4. D鲜花或盆栽植物
5.实验室检查值与电解质中等

On the first day after major surgery, a patient's white cell count is 12.5 × 10³/µL, with no fever or wound signs. What is the best interpretation?

  1. ADefinite wound infection that needs antibiotics now
  2. BA laboratory error, since surgery lowers white cells
  3. CA sign of leukemia that needs bone marrow testing
  4. DA common stress response to surgery that is monitored
6.实验室检查值与电解质困难

A patient has a hemoglobin of 11.2 g/dL (112 g/L), an MCV of 64 fL, a normal ferritin and a normal-to-high red cell count. What is the most likely cause?

  1. AThalassemia trait
  2. BVitamin B12 deficiency
  3. CAcute blood loss
  4. DIron deficiency
7.临床护理中等

一名患者腹部僵硬如板，因活动会加重疼痛而一动不动地躺着。这提示什么？

  1. A便秘
  2. B腹膜炎
  3. C消化不良
  4. D尿路感染
8.临床护理困难

A patient with a possible neck injury after a fall needs their airway opened. Which manoeuvre is preferred?

  1. AHead tilt with chin lift
  2. BJaw thrust
  3. CTurning the head to one side
  4. DHyperextending the neck
9.内外科护理：心血管与呼吸中等

A patient on home oxygen has dry, sore lips. Which product is safest to use?

  1. AAn alcohol-based gel
  2. BAn oil-based balm
  3. CPetroleum jelly
  4. DA water-based lubricant
10.内外科护理：心血管与呼吸困难

A smoker has severe shoulder and arm pain, a drooping eyelid, a small pupil and reduced sweating on the same side of the face. What should be suspected?

  1. AA simple migraine
  2. BA tumour at the apex of the lung (Pancoast tumour)
  3. CA stroke affecting the brainstem on the opposite side
  4. DA frozen shoulder with referred pain to the face
11.内外科护理：神经、内分泌与肾脏中等

Which group of drugs is a well-known cause of SIADH and hyponatraemia, especially in older people?

  1. APenicillin antibiotics
  2. BProton pump inhibitors
  3. CSSRI antidepressants
  4. DBulk-forming laxatives
12.内外科护理：神经、内分泌与肾脏困难

A patient with hypopituitarism needs both hydrocortisone and levothyroxine. Which is usually started first?

  1. ANeither, until symptoms appear
  2. BHydrocortisone
  3. CBoth on the same day, in any order
  4. DLevothyroxine
13.内外科护理：消化、围手术期与肿瘤中等

A patient takes co-codamol at home (a combination tablet sold under different names in different countries). Why should the nurse check this before giving regular paracetamol (acetaminophen)?

  1. ACo-codamol must be stopped a week before any paracetamol
  2. BIt already contains paracetamol, so overdose could occur
  3. CParacetamol and codeine cause a severe allergic reaction when combined
  4. DCo-codamol stops paracetamol from working
14.内外科护理：消化、围手术期与肿瘤困难

During preoperative assessment, a patient says their brother had a "very high fever" during an anaesthetic. What is the most important action?

  1. AInform the anaesthetist, as malignant hyperthermia may run in the family
  2. BReassure the patient that fevers after anaesthesia are always harmless
  3. CRecord it as a family allergy to paracetamol
  4. DGive paracetamol before surgery to prevent fever

3溶液

1.优先排序与委派

答案: C · 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

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

答案: B · 一名 2 岁的儿童，流口水，身体前倾，有喘鸣

为什么是这个答案

流口水、前倾（三脚架）姿势和喘鸣提示严重的上气道梗阻，如会厌炎，可能迅速变成完全梗阻。应让孩子保持平静，在气道专家到场之前不要检查咽喉。

答案

B · 一名 2 岁的儿童，流口水，身体前倾，有喘鸣
3.感染控制与患者安全

答案: B · A patient with diabetic peripheral neuropathy

为什么是这个答案

Reduced sensation, as in peripheral neuropathy, prevents a person from feeling heat damage. Patients with poor sensation, poor circulation or confusion need very close monitoring if heat is used at all.

答案

B · A patient with diabetic peripheral neuropathy
4.感染控制与患者安全

答案: D · 鲜花或盆栽植物

为什么是这个答案

鲜花和植物可携带曲霉菌（Aspergillus）等霉菌以及水源性细菌，可在严重免疫功能低下的患者中引起严重感染。干净、可擦拭的个人物品通常是允许的。

答案

D · 鲜花或盆栽植物
5.实验室检查值与电解质

答案: D · A common stress response to surgery that is monitored

为什么是这个答案

A mild leukocytosis is common after surgery because of tissue injury and the stress response. It is monitored along with temperature and wound assessment. A rising count after several days, or fever, suggests infection.核对依据: WBC count · MedlinePlus (NIH) (2025)

答案

D · A common stress response to surgery that is monitored
6.实验室检查值与电解质

答案: A · Thalassemia trait

为什么是这个答案

Thalassemia trait causes microcytosis from reduced globin production, often with a normal or high red cell count and normal ferritin. Iron deficiency has low ferritin. Iron supplements do not help thalassemia trait and can cause iron overload.核对依据: Thalassemia - Medical Encyclopedia · MedlinePlus (NIH) (2026); Red Blood Cell (RBC) Indices · MedlinePlus (NIH) (2024)

答案

A · Thalassemia trait
7.临床护理

答案: B · 腹膜炎

为什么是这个答案

腹膜炎（常由穿孔引起）会导致肌紧张、腹壁强直以及活动时疼痛加重。这是外科急症。

答案

B · 腹膜炎
8.临床护理

答案: B · Jaw thrust

为什么是这个答案

A jaw thrust opens the airway with minimal neck movement. The cervical spine is protected with manual in-line stabilisation, although opening the airway still takes priority if it remains obstructed.

答案

B · Jaw thrust
9.内外科护理：心血管与呼吸

答案: D · A water-based lubricant

为什么是这个答案

Oil-based products such as petroleum jelly can ignite or burn intensely in high oxygen concentrations and have caused facial burns. Water-based products are recommended. Oxygen cylinders are kept upright and secured, away from heat and flames.

答案

D · A water-based lubricant
10.内外科护理：心血管与呼吸

答案: B · A tumour at the apex of the lung (Pancoast tumour)

为什么是这个答案

A tumour in the lung apex can invade the brachial plexus (shoulder and arm pain) and the sympathetic chain, causing Horner's syndrome (ptosis, miosis, reduced sweating). It is a classic presentation of lung cancer that needs urgent imaging.

答案

B · A tumour at the apex of the lung (Pancoast tumour)
11.内外科护理：神经、内分泌与肾脏

答案: C · SSRI antidepressants

为什么是这个答案

SSRIs such as sertraline and citalopram can cause SIADH, particularly in older adults. Carbamazepine, some antipsychotics and some chemotherapy drugs are other causes. Sodium is checked if symptoms appear.

答案

C · SSRI antidepressants
12.内外科护理：神经、内分泌与肾脏

答案: B · Hydrocortisone

为什么是这个答案

Starting thyroid replacement first increases metabolism and cortisol clearance and can trigger an adrenal crisis in a patient with low cortisol. Glucocorticoid replacement is started before levothyroxine.

答案

B · Hydrocortisone
13.内外科护理：消化、围手术期与肿瘤

答案: B · It already contains paracetamol, so overdose could occur

为什么是这个答案

Co-codamol combines codeine and paracetamol. Giving extra paracetamol can exceed the maximum daily dose and cause liver damage, so all sources of paracetamol are counted.

答案

B · It already contains paracetamol, so overdose could occur
14.内外科护理：消化、围手术期与肿瘤

答案: A · Inform the anaesthetist, as malignant hyperthermia may run in the family

为什么是这个答案

Malignant hyperthermia susceptibility is inherited. The anaesthetist plans a trigger-free anaesthetic, avoiding volatile agents and suxamethonium, and the family may be referred for testing.

答案

A · Inform the anaesthetist, as malignant hyperthermia may run in the family

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