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 nurse gives IV morphine for severe pain. When should the nurse reassess the pain and sedation?

  1. AAt the next routine round in four hours
  2. BOnly when the patient asks for more
  3. CWithin about 15–30 minutes
  4. DAt the end of the shift
2.优先排序与委派困难

A patient has full-thickness burns all the way around the chest and is finding it harder to breathe, although the airway is clear. What does this suggest?

  1. AThe tight burned skin is restricting chest movement, so an escharotomy may be needed
  2. BThe patient is anxious and only needs reassurance
  3. CThe patient has had too little IV fluid and needs a fast bolus to improve the breathing
  4. DThe burns are healing and the skin is tightening normally
3.感染控制与患者安全中等

A patient with delirium is at risk of falls and of pulling out lines. Which option is less restrictive than restraints?

  1. AA sedative given every few hours as needed
  2. BA trained sitter or video monitoring with staff nearby
  3. CFour side rails raised and the door closed so the patient stays in bed
  4. DA vest restraint applied for the whole night
4.感染控制与患者安全困难

An IV bag from the pharmacy holds the correct drug, but the label shows another patient’s name. What should the nurse do?

  1. AAsk the patient whether it is fine to use the bag
  2. BNot hang it, and get a correctly labeled bag from the pharmacy
  3. CHang it, because the drug and dose are correct
  4. DCross out the name and write in the correct patient’s name
5.实验室检查值与电解质中等

A patient taking spironolactone asks about using a salt substitute. What should the nurse explain?

  1. ASalt substitutes protect against the potassium loss caused by this drug
  2. BMost salt substitutes contain potassium and can raise the level too high
  3. CSalt substitutes are safe because they contain only sodium chloride
  4. DSalt substitutes are fine as long as the patient drinks more water
6.实验室检查值与电解质困难

A stable patient's hemoglobin has been 13–14 g/dL for days. Today's result is 8.2 g/dL, but the patient feels well, the vital signs are normal and there is no bleeding. What should the nurse suspect first?

  1. ASudden massive internal bleeding
  2. BA normal day-to-day variation in Hb
  3. CA sample taken from the wrong patient
  4. DAcute bone marrow failure overnight
7.临床护理中等

Which group of symptoms suggests hypothyroidism?

  1. ATiredness, weight gain and feeling cold
  2. BExcessive thirst and passing large volumes of urine
  3. CFever, neck stiffness and photophobia
  4. DWeight loss, heat intolerance and tremor
8.临床护理困难

一名静脉滴注万古霉素的患者在快速输注时出现面部和颈部潮红及瘙痒性红疹。最可能的原因和处理是什么？

  1. A晒伤；涂抹乳膏后继续
  2. B肝衰竭；永久停用所有药物
  3. C正常反应；加快输注速度
  4. D输注相关反应；停止或减慢输注，并通知开药者
9.内外科护理：心血管与呼吸中等

Why must intravenous potassium chloride never be given as a rapid push or undiluted?

  1. AIt works only when given by mouth
  2. BIt immediately lowers the blood glucose to dangerous levels
  3. CA sudden high potassium level can cause cardiac arrest
  4. DIt turns into solid crystals inside the vein and blocks it
10.内外科护理：心血管与呼吸困难

一名服用比索洛尔和地尔硫䓬的患者头晕，心率 38 次/分，血压 82/50 mmHg。最恰当的首要应对是什么？

  1. A带患者在病房里走动以提高心率
  2. B呼叫紧急援助，进行 ABCDE 评估，并连接心脏监护仪
  3. C记录观察结果，四小时后复查
  4. D提前给两种药物的下一次剂量，以保持心率稳定
11.内外科护理：神经、内分泌与肾脏中等

A patient with migraine takes painkillers or triptans on most days and now has a headache almost every day. What is the likely problem?

  1. AA brain tumour, which is almost certain
  2. BAn allergy to the painkillers
  3. CNormal progress of migraine
  4. DMedication overuse headache
12.内外科护理：神经、内分泌与肾脏困难

A patient has had a high sodium of 160 mmol/L for several days. Why must it be corrected slowly?

  1. AThe sodium will rise again if corrected quickly
  2. BRapid correction can cause brain swelling
  3. CRapid correction causes kidney stones
  4. DRapid correction raises the blood glucose
13.内外科护理：消化、围手术期与肿瘤中等

Which lung problem is a known toxicity of bleomycin?

  1. APneumothorax from coughing
  2. BPulmonary fibrosis
  3. CLung cancer within weeks
  4. DAsthma from pollen
14.内外科护理：消化、围手术期与肿瘤困难

Just after extubation in recovery, a patient develops a high-pitched noise on breathing in, with falling SpO₂. What should the nurse do first?

  1. ASit the patient up and give a drink of water
  2. BGive an opioid to calm the patient's breathing and reduce anxiety
  3. CWait a few minutes to see if it passes
  4. DCall for help, give 100% oxygen and use a jaw thrust

3溶液

1.优先排序与委派

答案: C · Within about 15–30 minutes

为什么是这个答案

IV opioids act within minutes, so the nurse reassesses pain, sedation and breathing within about 15–30 minutes. Oral analgesics are usually reassessed later, after about an hour.

答案

C · Within about 15–30 minutes
2.优先排序与委派

答案: A · The tight burned skin is restricting chest movement, so an escharotomy may be needed

为什么是这个答案

Circumferential full-thickness burns form stiff eschar that can stop the chest expanding. An escharotomy, cutting through the eschar, may be needed urgently to allow breathing.

答案

A · The tight burned skin is restricting chest movement, so an escharotomy may be needed
3.感染控制与患者安全

答案: B · A trained sitter or video monitoring with staff nearby

为什么是这个答案

Close observation by a sitter or video monitoring allows staff to step in quickly, without restricting the patient. It is often combined with reorientation and family presence.

答案

B · A trained sitter or video monitoring with staff nearby
4.感染控制与患者安全

答案: B · Not hang it, and get a correctly labeled bag from the pharmacy

为什么是这个答案

A label with another patient’s name means the bag may be meant for someone else or may differ in other ways. The nurse does not use it, returns it and reports the issue so the error can be investigated.

答案

B · Not hang it, and get a correctly labeled bag from the pharmacy
5.实验室检查值与电解质

答案: B · Most salt substitutes contain potassium and can raise the level too high

为什么是这个答案

Spironolactone blocks aldosterone, so the kidneys keep potassium. Many salt substitutes are made of potassium chloride, and combining them with spironolactone can cause dangerous hyperkalemia, especially with kidney disease or ACE inhibitors.核对依据: Spironolactone · MedlinePlus (NIH) (2018); High potassium level · MedlinePlus (NIH) (2025)

答案

B · Most salt substitutes contain potassium and can raise the level too high
6.实验室检查值与电解质

答案: C · A sample taken from the wrong patient

为什么是这个答案

A sudden large change with no clinical change suggests a specimen error, such as wrong blood in the tube or dilution with IV fluid. The nurse assesses the patient, informs the provider and arranges a repeat sample with careful identification, while staying alert for true bleeding.

答案

C · A sample taken from the wrong patient
7.临床护理

答案: A · Tiredness, weight gain and feeling cold

为什么是这个答案

Low thyroid hormone slows metabolism, causing fatigue, weight gain, cold intolerance, constipation, dry skin and bradycardia. Weight loss, heat intolerance and tremor suggest hyperthyroidism.

答案

A · Tiredness, weight gain and feeling cold
8.临床护理

答案: D · 输注相关反应；停止或减慢输注，并通知开药者

为什么是这个答案

快速输注万古霉素可释放组胺，引起潮红和皮疹（"万古霉素输注反应"）。减慢速度通常可以预防，但必须排除过敏性休克。

答案

D · 输注相关反应；停止或减慢输注，并通知开药者
9.内外科护理：心血管与呼吸

答案: C · A sudden high potassium level can cause cardiac arrest

为什么是这个答案

Rapid or concentrated IV potassium can cause cardiac arrest. It is given diluted, by infusion, at controlled rates (often with a pump and ECG monitoring for higher rates). Concentrated ampoules are tightly controlled in hospitals because of fatal errors.

答案

C · A sudden high potassium level can cause cardiac arrest
10.内外科护理：心血管与呼吸

答案: B · 呼叫紧急援助，进行 ABCDE 评估，并连接心脏监护仪

为什么是这个答案

β 受体阻滞剂和减慢心率的钙通道阻滞剂对窦房结和房室结有叠加作用。伴有低血压的症状性心动过缓是急症：呼叫援助、监护、暂停这些药物，并按心动过缓流程预期使用阿托品，可能还需要起搏。

答案

B · 呼叫紧急援助，进行 ABCDE 评估，并连接心脏监护仪
11.内外科护理：神经、内分泌与肾脏

答案: D · Medication overuse headache

为什么是这个答案

Frequent use of painkillers or triptans can cause medication overuse headache. Treatment involves withdrawing the overused drug under guidance and starting a preventive treatment if needed.

答案

D · Medication overuse headache
12.内外科护理：神经、内分泌与肾脏

答案: B · Rapid correction can cause brain swelling

为什么是这个答案

In chronic hypernatraemia, brain cells adapt by holding extra solutes. If the sodium falls too quickly, water rushes into the cells and causes cerebral oedema and seizures. Correction is gradual, with regular sodium checks.

答案

B · Rapid correction can cause brain swelling
13.内外科护理：消化、围手术期与肿瘤

答案: B · Pulmonary fibrosis

为什么是这个答案

Bleomycin can cause pneumonitis and pulmonary fibrosis, especially at higher cumulative doses, in older patients and with high oxygen concentrations. Breathlessness or a new cough must be reported.

答案

B · Pulmonary fibrosis
14.内外科护理：消化、围手术期与肿瘤

答案: D · Call for help, give 100% oxygen and use a jaw thrust

为什么是这个答案

Stridor after extubation suggests laryngospasm or another upper airway obstruction. The nurse calls for help, applies high-flow oxygen and airway manoeuvres, and the anaesthetist may give drugs or reintubate.

答案

D · Call for help, give 100% oxygen and use a jaw thrust

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