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 teaches a patient who uses home oxygen. Which statement shows a need for further teaching?

  1. A“My husband can smoke in my room if the window is open.”
  2. B“I will put up no-smoking signs at the front door and in my room.”
  3. C“I will not use oil-based creams on my face.”
  4. D“I will keep the oxygen away from the gas stove.”
2.优先排序与委派困难

A patient receiving comfort-focused end-of-life care is distressed by breathlessness. Which approach is most appropriate?

  1. AGive prescribed opioids and use positioning and a fan to relieve breathlessness
  2. BLeave the patient alone so they can rest
  3. CWithhold all opioids because they may slow breathing
  4. DStart a series of aggressive tests to find the exact cause of the breathlessness
3.感染控制与患者安全中等

Why can side rails be dangerous for a confused, restless patient?

  1. ASide rails always cause pressure injuries
  2. BSide rails stop staff from reaching the patient in an emergency
  3. CSide rails make the bed move by itself
  4. DThe patient may climb over them or get trapped in gaps
4.感染控制与患者安全困难

A nurse finds that a patient has been taking their own sleeping pills from a bedside drawer while also receiving a hypnotic from the ward. What should the nurse do?

  1. ALet the patient keep them, since they are the patient’s own
  2. BThrow the patient’s pills away in the bin
  3. CSecure the home medication per policy and inform the provider
  4. DStop giving the hospital hypnotic without telling the provider or the pharmacy
5.实验室检查值与电解质中等

对于疑似脓毒症的患者，应在何时采集血培养？

  1. A在前三剂抗生素之后
  2. B在首剂抗生素之前，且不要过多延误给药
  3. C任何时候，因为抗生素不影响结果
  4. D仅在发热持续超过三天时
6.实验室检查值与电解质困难

一名肾功能正常、心电图正常的患者钾为 6.2 mEq/L。实验室备注样本发生了溶血。最好的解释是什么？

  1. A钾肯定是正常的，无需随访
  2. B患者有肾衰竭
  3. C结果可能是假性偏高；评估患者并安排重新采样
  4. D不再做进一步检查，立即用胰岛素和葡萄糖治疗
7.临床护理中等

A patient is receiving enteral feeding through a nasogastric tube. How should they be positioned during feeding?

  1. AIn any position, as long as the feed runs slowly
  2. BWith the head of the bed raised to at least 30 degrees
  3. CLying on the left side with the head down to help the feed drain
  4. DLying completely flat
8.临床护理困难

A patient with a central venous catheter needs the line removed. Which position reduces the risk of air embolism during removal of a neck or chest line?

  1. AStanding up and walking
  2. BLying flat or slightly head-down, holding the breath or breathing out
  3. CLying on the right side with the legs raised
  4. DSitting fully upright and taking a deep breath in as the line comes out
9.内外科护理：心血管与呼吸中等

A patient is starting long-term amiodarone. Which teaching and monitoring are most important?

  1. AExpect orange urine and no need for blood tests
  2. BEat extra salt and stop the drug as soon as the pulse is regular
  3. CAvoid dairy products and have the INR checked once at the start
  4. DProtect skin from sunlight and have thyroid, liver and lung checks
10.内外科护理：心血管与呼吸困难

一名哮喘患者有服用阿司匹林后喘息的病史。术后疼痛被开具了布洛芬。护士应怎么做？

  1. A暂停给药并要求更换其他药物
  2. B给药，因为布洛芬与阿司匹林无关
  3. C仅在疼痛评分高于 8/10 时给药
  4. D与缓解型吸入器同时给药
11.内外科护理：神经、内分泌与肾脏中等

In the first trimester of pregnancy, why is propylthiouracil often preferred to carbimazole for hyperthyroidism?

  1. APropylthiouracil works faster than any other drug
  2. BCarbimazole has a higher risk of birth defects early on
  3. CPropylthiouracil has no side effects at all
  4. DCarbimazole cannot cross into the mother's blood
12.内外科护理：神经、内分泌与肾脏困难

During a water deprivation test for suspected diabetes insipidus, the patient loses more than 3% of body weight and becomes hypotensive. What should the nurse do?

  1. AContinue the test, because this result is expected
  2. BStop the test and inform the doctor
  3. CGive desmopressin without a prescription
  4. DGive the patient a large drink and then restart the test
13.内外科护理：消化、围手术期与肿瘤中等

Why should metoclopramide not be used for nausea in mechanical bowel obstruction?

  1. AIt increases gut movement against the blockage
  2. BIt always causes severe diarrhoea
  3. CIt blocks the effect of all opioids
  4. DIt makes the bowel stop moving completely
14.内外科护理：消化、围手术期与肿瘤困难

A patient finds daily wound dressing changes very painful. What is the most effective nursing approach?

  1. AGive analgesia timed so it works during the dressing change
  2. BDo the dressing quickly and give analgesia afterwards
  3. CChange the dressing less often than the plan says
  4. DAvoid analgesia so the patient can report any problems during the change

3溶液

1.优先排序与委派

答案: A · “My husband can smoke in my room if the window is open.”

为什么是这个答案

Oxygen supports combustion, so no one may smoke near it, even with a window open. Keeping it away from flames and avoiding oil-based products are correct.

答案

A · “My husband can smoke in my room if the window is open.”
2.优先排序与委派

答案: A · Give prescribed opioids and use positioning and a fan to relieve breathlessness

为什么是这个答案

In palliative care, opioids are used to relieve breathlessness, along with positioning, a fan and calm reassurance. The aim is comfort, not more investigations.

答案

A · Give prescribed opioids and use positioning and a fan to relieve breathlessness
3.感染控制与患者安全

答案: D · The patient may climb over them or get trapped in gaps

为什么是这个答案

Confused patients may climb over rails and fall from a greater height or become trapped between the rail and mattress. Alternatives such as low beds and close observation are often safer.

答案

D · The patient may climb over them or get trapped in gaps
4.感染控制与患者安全

答案: C · Secure the home medication per policy and inform the provider

为什么是这个答案

Unrecorded home medicines can lead to duplicate doses, interactions and falls. They are stored or sent home according to policy, and the provider is told so the treatment plan can be reviewed.

答案

C · Secure the home medication per policy and inform the provider
5.实验室检查值与电解质

答案: B · 在首剂抗生素之前，且不要过多延误给药

为什么是这个答案

血培养应在使用抗生素之前采集，因为即使一剂抗生素也可能使细菌无法生长而掩盖病因。抗生素仍应尽快开始，最好在一小时内。

答案

B · 在首剂抗生素之前，且不要过多延误给药
6.实验室检查值与电解质

答案: C · 结果可能是假性偏高；评估患者并安排重新采样

为什么是这个答案

红细胞富含钾。当它们在试管中破裂（由于止血带过紧、握拳或针头太细）时，钾漏出，结果呈假性偏高。护士仍应评估患者并重复检测，因为不能漏掉真正的高钾血症。

答案

C · 结果可能是假性偏高；评估患者并安排重新采样
7.临床护理

答案: B · With the head of the bed raised to at least 30 degrees

为什么是这个答案

Keeping the head raised to at least 30–45° during feeding and for a period afterwards lowers the risk of aspiration pneumonia.

答案

B · With the head of the bed raised to at least 30 degrees
8.临床护理

答案: B · Lying flat or slightly head-down, holding the breath or breathing out

为什么是这个答案

A flat or head-down position and a Valsalva manoeuvre or breath-hold raise central venous pressure, reducing the risk of air being drawn in. An occlusive dressing is then applied.

答案

B · Lying flat or slightly head-down, holding the breath or breathing out
9.内外科护理：心血管与呼吸

答案: D · Protect skin from sunlight and have thyroid, liver and lung checks

为什么是这个答案

Amiodarone causes photosensitivity, thyroid dysfunction (it contains iodine), liver toxicity, pulmonary fibrosis and corneal deposits. Patients use high-factor sunscreen and have regular thyroid and liver tests and reviews for cough or breathlessness. It also interacts with warfarin and digoxin.

答案

D · Protect skin from sunlight and have thyroid, liver and lung checks
10.内外科护理：心血管与呼吸

答案: A · 暂停给药并要求更换其他药物

为什么是这个答案

在 NSAID 加重性呼吸道疾病中，阿司匹林和其他抑制 COX-1 的 NSAID 可诱发严重支气管痉挛。有阿司匹林反应史的患者，未经专科建议不应使用其他 NSAID。常规剂量的对乙酰氨基酚一般耐受良好。

答案

A · 暂停给药并要求更换其他药物
11.内外科护理：神经、内分泌与肾脏

答案: B · Carbimazole has a higher risk of birth defects early on

为什么是这个答案

Carbimazole is linked to congenital abnormalities when used in early pregnancy, so propylthiouracil is often used in the first trimester. Propylthiouracil can cause serious liver injury, so it is not preferred at other times.

答案

B · Carbimazole has a higher risk of birth defects early on
12.内外科护理：神经、内分泌与肾脏

答案: B · Stop the test and inform the doctor

为什么是这个答案

In DI, the patient keeps passing dilute urine despite fluid restriction and can become dangerously dehydrated. Significant weight loss, hypotension or a high sodium are reasons to stop the test and get medical review.

答案

B · Stop the test and inform the doctor
13.内外科护理：消化、围手术期与肿瘤

答案: A · It increases gut movement against the blockage

为什么是这个答案

Metoclopramide stimulates gastric and intestinal motility, which can worsen pain and risk perforation in complete mechanical obstruction. Other antiemetics are chosen.

答案

A · It increases gut movement against the blockage
14.内外科护理：消化、围手术期与肿瘤

答案: A · Give analgesia timed so it works during the dressing change

为什么是这个答案

Procedural pain is best managed by giving analgesia so its peak effect matches the procedure. Non-adherent dressings, soaking adherent dressings and allowing the patient to call pauses also help.

答案

A · Give analgesia timed so it works during the dressing change

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