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

Which postoperative patient should the nurse see first?

  1. ADressing soaked with bright red blood and a heart rate rising to 118/min
  2. BWants help with washing her hair before her visitors arrive this afternoon
  3. CPain of 4/10 one hour after an oral analgesic
  4. DAsking when the urinary catheter will be removed
2.优先排序与委派困难

A patient has central chest pain that started 30 minutes ago at rest and has not eased with rest or nitroglycerin. What does this suggest?

  1. AIndigestion that is best treated with an antacid and a glass of milk
  2. BA possible myocardial infarction that needs urgent action
  3. CMuscle strain that needs a warm compress
  4. DStable angina that will pass without treatment
3.感染控制与患者安全中等

A patient with diabetes will use lancets and insulin needles at home. Which teaching about disposal is correct?

  1. APut them loose in the household trash bag, as long as the bag is tied shut
  2. BPut them in a puncture-resistant container with a lid and follow local disposal rules
  3. CRecap each needle with two hands before putting it in the kitchen trash
  4. DFlush the used lancets and needles down the toilet
4.感染控制与患者安全困难

A patient receiving chemotherapy has an absolute neutrophil count of 400/mm3 (0.4 × 109/L) and a new temperature of 38.3 °C (100.9 °F). What should the nurse do?

  1. AReport it at once, because fever with severe neutropenia is an emergency
  2. BEncourage oral fluids and record the result in the chart
  3. CGive an antipyretic and reassess at the next routine round
  4. DRecheck the temperature in four hours before calling anyone about it
5.实验室检查值与电解质中等

A patient's potassium is unexpectedly 5.8 mEq/L. The sample was taken after the tourniquet was on for several minutes while the patient pumped their fist. What is the best interpretation?

  1. AThe result confirms true hyperkalemia and needs no further checking
  2. BThe result may be falsely high and should be repeated with better technique
  3. CFist pumping lowers potassium, so the true level is even higher
  4. DTourniquet time affects only the glucose result, not the potassium
6.实验室检查值与电解质困难

A patient with a heart murmur and fever has three sets of blood cultures, taken hours apart, all growing the same Streptococcus species. What does this suggest?

  1. AA urinary tract infection that has spread to the skin
  2. BContamination of all three samples during collection
  3. CA normal finding in patients with heart murmurs
  4. DPersistent bacteremia, as in infective endocarditis
7.临床护理中等

Why are patients advised to rinse their mouth after using an inhaled corticosteroid?

  1. ATo make the drug work faster
  2. BTo prevent tooth decay from the sugar in it
  3. CTo reduce the risk of oral thrush
  4. DTo stop the drug from being absorbed in the lungs
8.临床护理困难

护理水封式胸腔引流时，哪项做法正确？

  1. A保持引流瓶低于胸部水平
  2. B把引流瓶举过患者头顶来倒空
  3. C倒掉瓶中的水以防溢出
  4. D每次转运或移动床位时常规夹闭引流管
9.内外科护理：心血管与呼吸中等

A patient with COPD uses an inhaled corticosteroid combination inhaler. Which risk should the nurse be aware of?

  1. AA sharp drop in potassium after each dose
  2. BAn increased risk of high blood pressure crises
  3. CAn increased risk of pneumonia
  4. DHearing loss after every dose
10.内外科护理：心血管与呼吸困难

Three days after an MI, a patient faints on the commode while straining hard to open the bowels. The heart rate was 42/min at the time. What is the most likely mechanism?

  1. AAn allergic reaction to the commode
  2. BA new pulmonary embolism
  3. CLow blood glucose from fasting
  4. DA vagal response to straining
11.内外科护理：神经、内分泌与肾脏中等

A patient has acute glomerulonephritis with oedema and high blood pressure. Which nursing care is most appropriate?

  1. ACheck the weight once a week
  2. BMonitor BP, fluid balance and daily weight
  3. CGive large amounts of IV fluid
  4. DEncourage a high-salt diet to balance the fluids
12.内外科护理：神经、内分泌与肾脏困难

A patient with gastroparesis has hypos soon after their meal-time insulin, then high glucose several hours later. What is the best explanation?

  1. AThe insulin has gone off and needs replacing
  2. BFood is absorbed slowly, so the insulin peaks before the glucose rises
  3. CThe patient is secretly eating sweets between meals
  4. DThe meter gives false results for several hours after every meal
13.内外科护理：消化、围手术期与肿瘤中等

限钠和螺内酯在肝硬化中起什么作用？

  1. A升高血压并改善肾血流
  2. B增加钾丢失并预防高钾血症
  3. C降低血氨并治疗脑病
  4. D减少钠水潴留并控制腹水
14.内外科护理：消化、围手术期与肿瘤困难

一名患者正在接受负压伤口治疗。泵报警，敷料失去了密封。最恰当的措施是什么？

  1. A恢复密封；如果及时无法恢复，改用湿性敷料
  2. B把吸力调到最大设置以拉回密封
  3. C在泡沫上用干纱布填塞伤口，并用胶带贴紧
  4. D把泡沫留在伤口内、不吸引，直到数天后复查

3溶液

1.优先排序与委派

答案: A · Dressing soaked with bright red blood and a heart rate rising to 118/min

为什么是这个答案

Heavy fresh bleeding with a rising heart rate suggests hemorrhage and early shock. The other patients have routine needs that can wait.

答案

A · Dressing soaked with bright red blood and a heart rate rising to 118/min
2.优先排序与委派

答案: B · A possible myocardial infarction that needs urgent action

为什么是这个答案

Chest pain that lasts and is not relieved by rest or nitroglycerin suggests acute coronary syndrome, possibly a heart attack. The nurse acts at once: ECG, escalation and prescribed treatment.

答案

B · A possible myocardial infarction that needs urgent action
3.感染控制与患者安全

答案: B · Put them in a puncture-resistant container with a lid and follow local disposal rules

为什么是这个答案

Home sharps go into a puncture-resistant container, such as an approved sharps container or a rigid plastic bottle if local rules allow, which is closed and disposed of according to local guidance.

答案

B · Put them in a puncture-resistant container with a lid and follow local disposal rules
4.感染控制与患者安全

答案: A · Report it at once, because fever with severe neutropenia is an emergency

为什么是这个答案

Febrile neutropenia can progress to sepsis quickly. The nurse reports it immediately so cultures can be taken and antibiotics started without delay.

答案

A · Report it at once, because fever with severe neutropenia is an emergency
5.实验室检查值与电解质

答案: B · The result may be falsely high and should be repeated with better technique

为什么是这个答案

Repeated fist clenching and a long tourniquet time release potassium from muscle and can cause hemolysis, both of which give a falsely high potassium. The patient is assessed and the test is repeated with correct technique; true hyperkalemia must not be missed.核对依据: Potassium Blood Test · MedlinePlus (NIH) (2024); Potassium test · MedlinePlus (NIH) (2025)

答案

B · The result may be falsely high and should be repeated with better technique
6.实验室检查值与电解质

答案: D · Persistent bacteremia, as in infective endocarditis

为什么是这个答案

Several positive cultures with the same organism, taken at different times, show continuous bacteremia, typical of infective endocarditis. Echocardiography is done and prolonged IV antibiotics are started. Contamination usually affects only one bottle.核对依据: Blood culture · MedlinePlus (NIH) (2025)

答案

D · Persistent bacteremia, as in infective endocarditis
7.临床护理

答案: C · To reduce the risk of oral thrush

为什么是这个答案

Inhaled steroid deposited in the mouth and throat can cause oral candidiasis and a hoarse voice. Rinsing and using a spacer reduce this.

答案

C · To reduce the risk of oral thrush
8.临床护理

答案: A · 保持引流瓶低于胸部水平

为什么是这个答案

引流瓶应低于胸部，防止液体和气体回流入胸膜腔。常规夹管可能导致张力性气胸。

答案

A · 保持引流瓶低于胸部水平
9.内外科护理：心血管与呼吸

答案: C · An increased risk of pneumonia

为什么是这个答案

In COPD, inhaled corticosteroids increase the risk of pneumonia. They are used where there are frequent exacerbations or features of asthma, and their benefit is weighed against this risk. Signs of pneumonia should be reported promptly.

答案

C · An increased risk of pneumonia
10.内外科护理：心血管与呼吸

答案: D · A vagal response to straining

为什么是这个答案

Straining (the Valsalva manoeuvre) can cause a vagal bradycardia and a fall in cardiac output, leading to syncope. After an MI, stool softeners, adequate fluids and avoiding straining are advised. The event is still reported and the patient assessed for arrhythmia or ischaemia.

答案

D · A vagal response to straining
11.内外科护理：神经、内分泌与肾脏

答案: B · Monitor BP, fluid balance and daily weight

为什么是这个答案

In acute glomerulonephritis, salt and water retention cause oedema and hypertension. Close monitoring of BP, input and output and daily weights is needed, often with salt and fluid restriction and antihypertensives.

答案

B · Monitor BP, fluid balance and daily weight
12.内外科护理：神经、内分泌与肾脏

答案: B · Food is absorbed slowly, so the insulin peaks before the glucose rises

为什么是这个答案

Delayed gastric emptying means carbohydrate reaches the blood later than expected. The insulin acts too early, causing a hypo, and glucose rises later. The prescriber may change the timing, for example giving the insulin after the meal.

答案

B · Food is absorbed slowly, so the insulin peaks before the glucose rises
13.内外科护理：消化、围手术期与肿瘤

答案: D · 减少钠水潴留并控制腹水

为什么是这个答案

在肝硬化中，继发性醛固酮增多症引起钠水潴留。限钠和醛固酮拮抗剂螺内酯（常与袢利尿剂联用）可减少腹水。螺内酯可引起高钾血症和男性乳房发育。

答案

D · 减少钠水潴留并控制腹水
14.内外科护理：消化、围手术期与肿瘤

答案: A · 恢复密封；如果及时无法恢复，改用湿性敷料

为什么是这个答案

NPWT 需要气密的密封。如果密封或吸力丧失且不能及时恢复（许多指南规定约 2 小时内），应取出泡沫并换成标准敷料，以降低感染风险。安全间隔由制造商和当地指南规定。

答案

A · 恢复密封；如果及时无法恢复，改用湿性敷料

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