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 patient is raising his voice, pacing and clenching his fists. What should the nurse do first?

  1. AApply physical restraints at once
  2. BTurn away and ignore the behavior
  3. CSpeak calmly, keep a safe distance and invite him to talk about what is wrong
  4. DStand very close to him and tell him firmly and loudly to sit down and be quiet
2.优先排序与委派困难

A nurse sees a colleague put a vial of an opioid into their own pocket instead of returning it. What should the nurse do?

  1. AReport it to the nurse manager according to policy
  2. BSay nothing, because it is not their business
  3. CTell the patients to watch the colleague carefully
  4. DAsk the colleague to share the vial with them
3.感染控制与患者安全中等

Where is a gait belt placed when helping a patient to walk?

  1. AAround the hips, directly on bare skin
  2. BAround the patient’s waist, over clothing
  3. CAround both thighs, just above the knees
  4. DAround the chest, under the arms
4.感染控制与患者安全困难

In START triage at a mass-casualty incident, a casualty cannot walk, breathes 20 times a minute, has a radial pulse and follows simple commands. Which category applies?

  1. ARed (immediate)
  2. BBlack (expectant or dead)
  3. CYellow (delayed)
  4. DGreen (minor)
5.实验室检查值与电解质中等

How does the nurse start a 24-hour urine collection at 08:00?

  1. ACollect only the first urine passed on waking, and repeat this the next morning
  2. BHave the patient void and discard that urine, then save all urine until 08:00 the next day
  3. CSave the 08:00 urine as the first sample, then collect until 08:00 the next day
  4. DSave three samples spread across the day and discard all of the urine passed at night
6.实验室检查值与电解质困难

A patient has sudden episodes of severe headache, sweating, palpitations and very high blood pressure. Which test is most useful to look for the cause?

  1. ASerum calcium only
  2. BFasting lipid profile
  3. CSerum TSH and free T4
  4. DPlasma free metanephrines
7.临床护理中等

Which statement about storing insulin is correct?

  1. AUnopened insulin is kept in the fridge and must not be frozen
  2. BInsulin should be kept in direct sunlight
  3. CAll insulin should be stored in the freezer to keep it fresh
  4. DInsulin never expires once opened
8.临床护理困难

Which statement about oxygen in a patient with suspected acute coronary syndrome is correct?

  1. AOxygen replaces the need for an ECG
  2. BOxygen must never be given in chest pain
  3. CHigh-flow oxygen should always be given, whatever the SpO2
  4. DOxygen is given if the SpO2 is below the target range
9.内外科护理：心血管与呼吸中等

How should a patient breathe in when using a dry powder inhaler?

  1. ASlowly and gently over about ten seconds
  2. BSeveral times, breathing out into the device between breaths
  3. CThrough the nose with the mouthpiece in the mouth
  4. DQuickly and deeply, after breathing out away from the device
10.内外科护理：心血管与呼吸困难

The stump of a recent below-knee amputation suddenly bleeds heavily through the dressing. What should the nurse do first?

  1. AEncourage the patient to walk on crutches to ease the pressure
  2. BApply a warm compress to the stump
  3. CApply firm direct pressure and call for urgent surgical help
  4. DRemove all the dressings and wait for the bleeding to stop by itself
11.内外科护理：神经、内分泌与肾脏中等

Which blood gas pattern is typical of acute kidney injury?

  1. AHigh pH and high bicarbonate
  2. BHigh pH and low carbon dioxide
  3. CLow pH and high carbon dioxide only
  4. DLow pH and low bicarbonate
12.内外科护理：神经、内分泌与肾脏困难

A patient with type 1 diabetes has a seizure on the ward. Their capillary glucose is 1.9 mmol/L (34 mg/dL). They cannot swallow. What is the most appropriate treatment?

  1. AA rapid-acting insulin dose to stabilise the glucose
  2. BIV glucose or IM glucagon, then recheck the glucose
  3. CAn antiepileptic drug only, because seizures need seizure treatment
  4. DGlucose gel squeezed into the mouth during the seizure
13.内外科护理：消化、围手术期与肿瘤中等

During the first infusion of a monoclonal antibody such as rituximab, which problem is most important to watch for?

  1. AA rise in platelet count above normal
  2. BAn infusion reaction, such as fever, rigors or breathlessness
  3. CSudden hair loss during the infusion
  4. DSevere constipation within the first hour of starting the infusion
14.内外科护理：消化、围手术期与肿瘤困难

A patient has sharp, tearing pain on passing stool, "like passing glass", with a streak of fresh blood. Which condition is most likely?

  1. AColorectal cancer
  2. BAnal fissure
  3. CCrohn's disease of the ileum
  4. DUpper GI bleeding

3溶液

1.优先排序与委派

答案: C · Speak calmly, keep a safe distance and invite him to talk about what is wrong

为什么是这个答案

Early verbal de-escalation, with a calm voice and a safe distance, is the first approach for rising agitation. Restraint is a last resort, and crowding the patient can make things worse.

答案

C · Speak calmly, keep a safe distance and invite him to talk about what is wrong
2.优先排序与委派

答案: A · Report it to the nurse manager according to policy

为什么是这个答案

Suspected drug diversion must be reported through the proper channel, usually the manager. It protects patients and allows the colleague to get help; staying silent is not acceptable.

答案

A · Report it to the nurse manager according to policy
3.感染控制与患者安全

答案: B · Around the patient’s waist, over clothing

为什么是这个答案

The gait belt goes snugly around the waist over clothing, close to the center of gravity, with room for the nurse’s fingers underneath. Holding it gives control without pulling on the arms.

答案

B · Around the patient’s waist, over clothing
4.感染控制与患者安全

答案: C · Yellow (delayed)

为什么是这个答案

The casualty cannot walk, so is not green. Breathing is under 30 a minute, perfusion is adequate and they obey commands, so none of the red criteria apply. This makes them yellow, delayed.

答案

C · Yellow (delayed)
5.实验室检查值与电解质

答案: B · Have the patient void and discard that urine, then save all urine until 08:00 the next day

为什么是这个答案

The collection starts with an empty bladder, so the first void is discarded and the time recorded. All urine for the next 24 hours is saved, including a final void at the end time. If urine is discarded by mistake, the collection usually has to restart.核对依据: Urine 24-hour volume · MedlinePlus (NIH) (2025)

答案

B · Have the patient void and discard that urine, then save all urine until 08:00 the next day
6.实验室检查值与电解质

答案: D · Plasma free metanephrines

为什么是这个答案

These episodes suggest pheochromocytoma, a tumor of the adrenal medulla that releases catecholamines. Plasma free metanephrines (or 24-hour urine metanephrines) are the main screening tests. Hyperthyroidism can cause similar symptoms but usually without these bursts of severe hypertension.核对依据: Pheochromocytoma · MedlinePlus (NIH) (2024)

答案

D · Plasma free metanephrines
7.临床护理

答案: A · Unopened insulin is kept in the fridge and must not be frozen

为什么是这个答案

Unopened insulin is refrigerated; in-use pens or vials are usually kept at room temperature for a limited time stated by the manufacturer. Frozen or overheated insulin must be discarded.

答案

A · Unopened insulin is kept in the fridge and must not be frozen
8.临床护理

答案: D · Oxygen is given if the SpO2 is below the target range

为什么是这个答案

Current guidance recommends oxygen in ACS only for hypoxaemia, as routine oxygen in patients with normal saturations has not been shown to help. Urgent ECG, analgesia and antiplatelet treatment remain priorities.

答案

D · Oxygen is given if the SpO2 is below the target range
9.内外科护理：心血管与呼吸

答案: D · Quickly and deeply, after breathing out away from the device

为什么是这个答案

Dry powder inhalers have no propellant, so a fast, deep inhalation is needed to disperse the powder. The patient breathes out away from the device first, because moist breath can clump the powder. Very weak or breathless patients may not manage this.

答案

D · Quickly and deeply, after breathing out away from the device
10.内外科护理：心血管与呼吸

答案: C · Apply firm direct pressure and call for urgent surgical help

为什么是这个答案

Haemorrhage from a stump needs immediate direct pressure, elevation if appropriate, and urgent surgical help. A tourniquet should be available as policy directs. Vital signs are monitored for shock.

答案

C · Apply firm direct pressure and call for urgent surgical help
11.内外科护理：神经、内分泌与肾脏

答案: D · Low pH and low bicarbonate

为什么是这个答案

Failing kidneys cannot excrete acid or regenerate bicarbonate, causing a metabolic acidosis with low pH and low bicarbonate. The patient may breathe faster to blow off CO2 as compensation.

答案

D · Low pH and low bicarbonate
12.内外科护理：神经、内分泌与肾脏

答案: B · IV glucose or IM glucagon, then recheck the glucose

为什么是这个答案

Severe hypoglycaemia can cause seizures. A patient who cannot swallow needs IV glucose, or IM glucagon if there is no IV access. Nothing should be put in the mouth of a fitting or unconscious patient. Glucose is rechecked and a long-acting carbohydrate is given when safe.

答案

B · IV glucose or IM glucagon, then recheck the glucose
13.内外科护理：消化、围手术期与肿瘤

答案: B · An infusion reaction, such as fever, rigors or breathlessness

为什么是这个答案

Infusion-related reactions are most common with the first dose. Premedication, a slow starting rate, close monitoring and readiness to stop the infusion and treat anaphylaxis are standard.

答案

B · An infusion reaction, such as fever, rigors or breathlessness
14.内外科护理：消化、围手术期与肿瘤

答案: B · Anal fissure

为什么是这个答案

An anal fissure causes severe pain during and after defecation with bright red blood. Treatment includes stool softeners, fibre and topical treatment to relax the sphincter.

答案

B · Anal fissure

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