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

Which SBAR recommendation is the clearest?

  1. A“He seems a bit off tonight, so maybe you could come up and do something about it.”
  2. B“I will keep watching him and call again tomorrow.”
  3. C“I just wanted to let you know about him.”
  4. D“I would like you to see him within 15 minutes and consider a fluid bolus.”
2.优先排序与委派困难

在 START 分诊中，一名不能行走的成人每分钟呼吸 24 次，有桡动脉搏动，但不能遵从简单指令。该伤员被归入哪一类？

  1. A红色（立即）
  2. B黑色（期待观察）
  3. C绿色（轻伤）
  4. D黄色（延迟）
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 vest restraint applied for the whole night
  2. BA trained sitter or video monitoring with staff nearby
  3. CA sedative given every few hours as needed
  4. DFour side rails raised and the door closed so the patient stays in bed
4.感染控制与患者安全困难

给一名有窒息风险的清醒患者口服药物。哪种做法最安全？

  1. A不检查是否允许就把所有药片碾碎
  2. B让患者坐直，一次给一片药
  3. C让患者仰卧平躺，使吞咽更容易
  4. D为节省时间一次给完所有药片
5.实验室检查值与电解质中等

A patient with central diabetes insipidus starts desmopressin. Which laboratory result is most important to monitor for an adverse effect?

  1. ASerum glucose, which may rise very high
  2. BSerum sodium, which may fall too low
  3. CSerum calcium, which may rise too high
  4. DSerum potassium, which may rise too high
6.实验室检查值与电解质困难

A patient with long-standing rheumatoid arthritis has a hemoglobin of 10.5 g/dL (105 g/L), a low serum iron, a low total iron-binding capacity (TIBC) and a high-normal ferritin. Which condition fits best?

  1. AVitamin B12 deficiency anemia
  2. BAnemia of chronic disease (inflammation)
  3. CIron-deficiency anemia
  4. DAcute blood loss anemia
7.临床护理中等

During a vesicant chemotherapy infusion, the patient reports burning and swelling at the cannula site. What should the nurse do first?

  1. AFlush the cannula hard with saline
  2. BApply a warm pack and continue the infusion
  3. CStop the infusion straight away and follow the extravasation protocol
  4. DIncrease the rate so that the infusion finishes as quickly as possible
8.临床护理困难

A patient suddenly develops a painful red eye with blurred vision, haloes around lights and vomiting. What should be suspected?

  1. AA stye
  2. BAcute angle-closure glaucoma
  3. CSimple conjunctivitis from a viral infection
  4. DDry eye syndrome
9.内外科护理：心血管与呼吸中等

为什么缺血性心脏病患者不应突然停用 β 受体阻滞剂？

  1. A药物会在组织中储存数月
  2. B停药后心率会永久性变慢
  3. C突然停药会引起严重而持久的低血糖
  4. D反跳性心动过速和高血压可诱发心绞痛或心肌梗死
10.内外科护理：心血管与呼吸困难

Two days after coronary artery bypass surgery, a patient feels palpitations. The pulse is irregularly irregular at 140/min and BP is 112/70 mmHg. Which rhythm is most likely?

  1. AAtrial fibrillation
  2. BVentricular fibrillation
  3. CComplete heart block
  4. DSinus tachycardia
11.内外科护理：神经、内分泌与肾脏中等

Why is an ACE inhibitor often given to a patient with diabetes and albumin in the urine?

  1. AIt raises potassium to protect the heart
  2. BIt lowers the blood glucose to normal
  3. CIt stops the kidneys from passing so much urine at night
  4. DIt protects the kidneys and reduces albumin loss
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. BGive desmopressin without a prescription
  3. CGive the patient a large drink and then restart the test
  4. DStop the test and inform the doctor
13.内外科护理：消化、围手术期与肿瘤中等

Which description fits a category (stage) 4 pressure ulcer?

  1. AA shallow wound into the dermis only
  2. BA blister filled with clear fluid over the heel or sacrum
  3. CIntact skin with redness that does not blanch
  4. DFull-thickness loss with exposed bone, tendon or muscle
14.内外科护理：消化、围手术期与肿瘤困难

一名小肠梗阻患者的鼻胃管每天引流 2 L。哪项护理重点最重要？

  1. A长时间夹闭导管以保留胃液
  2. B随意给予口服液体来补充导管引出的量
  3. C准确的液体平衡，配合静脉补充和电解质检查
  4. D引流 1 L 后拔除导管以防丢失

3溶液

1.优先排序与委派

答案: D · “I would like you to see him within 15 minutes and consider a fluid bolus.”

为什么是这个答案

A good recommendation is specific about the request and the time frame. Vague statements leave the provider unsure how urgent the problem is.

答案

D · “I would like you to see him within 15 minutes and consider a fluid bolus.”
2.优先排序与委派

答案: A · 红色（立即）

为什么是这个答案

未通过意识状态检查（不能遵从简单指令）的伤员为立即，即使呼吸和灌注可以接受。这可能提示头部损伤或休克。

答案

A · 红色（立即）
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 · 让患者坐直，一次给一片药

为什么是这个答案

直立体位和一次给一种药可降低窒息风险。只有在药房确认安全后才可碾碎，因为一些缓释和肠溶制剂碾碎后会有危险。

答案

B · 让患者坐直，一次给一片药
5.实验室检查值与电解质

答案: B · Serum sodium, which may fall too low

为什么是这个答案

Desmopressin acts like ADH, so the kidneys retain water. If the patient drinks too much, water retention can cause hyponatremia, which may lead to confusion and seizures. Sodium, weight and fluid balance are monitored.

答案

B · Serum sodium, which may fall too low
6.实验室检查值与电解质

答案: B · Anemia of chronic disease (inflammation)

为什么是这个答案

In chronic inflammation, iron is trapped in stores, so serum iron is low but ferritin is normal or high and TIBC is low. In iron deficiency, ferritin is low and TIBC is high. Iron supplements help iron deficiency much more than anemia of chronic disease.

答案

B · Anemia of chronic disease (inflammation)
7.临床护理

答案: C · Stop the infusion straight away and follow the extravasation protocol

为什么是这个答案

Suspected extravasation of a vesicant needs the infusion stopped immediately. Local protocols then guide aspiration through the cannula, specific treatments, elevation, documentation and specialist review.

答案

C · Stop the infusion straight away and follow the extravasation protocol
8.临床护理

答案: B · Acute angle-closure glaucoma

为什么是这个答案

Acute angle-closure glaucoma causes a rapid rise in eye pressure, with pain, visual disturbance, haloes and vomiting. It is an emergency that can cause permanent sight loss without urgent treatment.

答案

B · Acute angle-closure glaucoma
9.内外科护理：心血管与呼吸

答案: D · 反跳性心动过速和高血压可诱发心绞痛或心肌梗死

为什么是这个答案

长期 β 受体阻滞会使 β 受体的数量增多、敏感性增强。突然停药使它们暴露于正常水平的肾上腺素，可引起反跳性心动过速、高血压和心肌缺血。应逐渐减量。

答案

D · 反跳性心动过速和高血压可诱发心绞痛或心肌梗死
10.内外科护理：心血管与呼吸

答案: A · Atrial fibrillation

为什么是这个答案

New atrial fibrillation affects a large proportion of patients in the first days after cardiac surgery, often due to inflammation, electrolyte shifts and stress. Management includes a 12-lead ECG, checking potassium and magnesium, rate or rhythm control and considering anticoagulation.

答案

A · Atrial fibrillation
11.内外科护理：神经、内分泌与肾脏

答案: D · It protects the kidneys and reduces albumin loss

为什么是这个答案

ACE inhibitors and ARBs reduce glomerular pressure, lower albuminuria and slow the progression of diabetic kidney disease, as well as treating blood pressure. Potassium and creatinine are checked after starting them.

答案

D · It protects the kidneys and reduces albumin loss
12.内外科护理：神经、内分泌与肾脏

答案: D · 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

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

答案: D · Full-thickness loss with exposed bone, tendon or muscle

为什么是这个答案

Category 4 has full-thickness loss with exposed bone, tendon or muscle and often undermining or tunnelling. Category 3 reaches the fat but does not expose bone, tendon or muscle.

答案

D · Full-thickness loss with exposed bone, tendon or muscle
14.内外科护理：消化、围手术期与肿瘤

答案: C · 准确的液体平衡，配合静脉补充和电解质检查

为什么是这个答案

鼻胃管大量丢失可引起脱水、低钾血症和低氯性代谢性碱中毒。应测量并记录引流量，按医嘱静脉补充（常用含钾晶体液），并至少每天检查尿素、肌酐和电解质。口服液体会增加丢失和呕吐风险。

答案

C · 准确的液体平衡，配合静脉补充和电解质检查

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