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

在病房发生心脏骤停时，确认患者无反应且没有正常呼吸之后，首先做什么？

  1. A给两次人工呼吸，然后检查脉搏一分钟
  2. B在呼救之前先找到患者的病历，核对复苏状态
  3. C呼救并开始胸外按压
  4. D测量血压
2.优先排序与委派困难

A patient with known abdominal aortic aneurysm suddenly has severe back pain, a pulsing mass in the abdomen and a falling blood pressure. What should the nurse do?

  1. AGive an oral analgesic and reassess the patient in about one hour
  2. BEncourage the patient to walk to ease the back pain
  3. CCall for emergency help at once and prepare for urgent surgery
  4. DPalpate the mass firmly to check its size and spread
3.感染控制与患者安全中等

A patient has received oral radioactive iodine therapy. Which precaution is usually taken?

  1. AEncourage pregnant visitors to sit close to the patient to give emotional support
  2. BLet the patient share a bathroom with other patients
  3. CLimit time close to the patient and handle body fluids per radiation policy
  4. DPlace the patient on droplet precautions with a surgical mask
4.感染控制与患者安全困难

一名意识混乱的患者不断拉扯鼻胃管。应首先尝试哪种方法？

  1. A给予镇静剂，让患者整夜安静睡觉
  2. B立即使用腕部约束以保护管道
  3. C不咨询团队就拔掉管道
  4. D限制性较小的措施，如重新定向和陪护
5.实验室检查值与电解质中等

A breathless patient in the emergency department has a BNP below 100 pg/mL. What does this suggest?

  1. ASevere heart failure is certainly the cause of the problem
  2. BThe kidneys are failing and the patient needs dialysis
  3. CHeart failure is an unlikely cause of the breathlessness
  4. DThe patient has had a myocardial infarction in the past day
6.实验室检查值与电解质困难

Four patients had a thyroidectomy earlier today. Which result should the nurse act on first?

  1. AHemoglobin 12.1 g/dL (121 g/L) after surgery
  2. BCalcium 7.2 mg/dL (1.8 mmol/L) with tingling lips
  3. CGlucose 145 mg/dL (8.0 mmol/L) after surgery
  4. DSodium 136 mEq/L on IV fluids after surgery
7.临床护理中等

为什么对疑似脓毒症的患者要测定血清乳酸？

  1. A它能确定该用哪种抗生素
  2. B它测量患者的血糖
  3. C乳酸升高表明组织灌注不良、风险更高
  4. D它显示患者是否有尿路感染
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. ADry eye syndrome
  2. BA stye
  3. CAcute angle-closure glaucoma
  4. DSimple conjunctivitis from a viral infection
9.内外科护理：心血管与呼吸中等

Which investigation is usually used to confirm a deep vein thrombosis in the leg?

  1. AA plain chest X-ray and an ECG
  2. BCompression duplex ultrasound
  3. CAn exercise ECG
  4. DA lung function test
10.内外科护理：心血管与呼吸困难

A patient receiving weeks of IV antibiotics through a PICC line in the left arm develops swelling and aching of that arm and neck veins that look fuller on the left. What should the nurse suspect?

  1. AA local skin allergy to the dressing
  2. BLymphoedema from lying in bed
  3. CA catheter-related deep vein thrombosis
  4. DAn expected effect of the antibiotic
11.内外科护理：神经、内分泌与肾脏中等

A patient with multiple sclerosis says their symptoms get worse after a hot bath. What should the nurse explain?

  1. AHot baths cause new areas of damage in the brain
  2. BThis shows that the disease has entered a new progressive stage
  3. CThey should take very cold baths to reverse the damage
  4. DHeat can briefly worsen MS symptoms, which settle when they cool down
12.内外科护理：神经、内分泌与肾脏困难

一名卒中并右侧肢体无力的患者准备从床转移到椅子上。哪种方法最安全？

  1. A把椅子放在右侧，并拉着患侧手臂提起
  2. B让患者独自站起并走到椅子上
  3. C把椅子放在左侧，并向椅子方向转身
  4. D拉着右肩和手腕把患者拉起来
13.内外科护理：消化、围手术期与肿瘤中等

A patient on warfarin is booked for elective surgery with a high bleeding risk. What is usual practice?

  1. ATake the usual dose on the morning of surgery
  2. BStop it about 5 days before and check the INR
  3. CDouble the dose for a week so the blood is ready for surgery
  4. DSwap to aspirin on the morning of surgery
14.内外科护理：消化、围手术期与肿瘤困难

全身麻醉期间，一名患者出现下颌强直、呼气末 CO₂ 升高和心动过速，随后体温迅速上升。哪种药物是特异性治疗？

  1. A丹曲林
  2. B琥珀酰胆碱
  3. C纳洛酮
  4. D对乙酰氨基酚

3溶液

1.优先排序与委派

答案: C · 呼救并开始胸外按压

为什么是这个答案

呼救（骤停团队和除颤器）并立即开始高质量的按压。长时间检查脉搏、延误或测量血压都是浪费时间。如有可能，应事先知道复苏状态。

答案

C · 呼救并开始胸外按压
2.优先排序与委派

答案: C · Call for emergency help at once and prepare for urgent surgery

为什么是这个答案

Sudden severe back or abdominal pain with hypotension in a patient with an aneurysm suggests rupture, which is fatal without urgent surgery. The mass should not be palpated firmly.

答案

C · Call for emergency help at once and prepare for urgent surgery
3.感染控制与患者安全

答案: C · Limit time close to the patient and handle body fluids per radiation policy

为什么是这个答案

Radioactive iodine is excreted in urine, sweat and saliva, so the patient is usually in a private room with their own bathroom. Staff limit time near them, use distance and follow policy for body fluids and waste.

答案

C · Limit time close to the patient and handle body fluids per radiation policy
4.感染控制与患者安全

答案: D · 限制性较小的措施，如重新定向和陪护

为什么是这个答案

应先尝试限制性较小的措施：重新定向、查找疼痛等原因、把管道固定在看不到的位置，以及安排人员陪伴患者。只有这些措施无效且患者有风险时，才在有医嘱的情况下使用约束或镇静剂。

答案

D · 限制性较小的措施，如重新定向和陪护
5.实验室检查值与电解质

答案: C · Heart failure is an unlikely cause of the breathlessness

为什么是这个答案

BNP is released from stretched ventricles, so a low value makes heart failure an unlikely cause of acute breathlessness. A high value supports heart failure, but BNP also rises with age, kidney disease and pulmonary embolism.核对依据: Natriuretic Peptide Tests (BNP, NT-proBNP) · MedlinePlus (NIH) (2023)

答案

C · Heart failure is an unlikely cause of the breathlessness
6.实验室检查值与电解质

答案: B · Calcium 7.2 mg/dL (1.8 mmol/L) with tingling lips

为什么是这个答案

Hypocalcemia after thyroid surgery, from parathyroid injury, can progress to tetany and laryngospasm. Tingling lips are an early sign, so the nurse assesses the airway and Chvostek and Trousseau signs and reports at once. The other results are expected after surgery.核对依据: Calcium Blood Test · MedlinePlus (NIH) (2024)

答案

B · Calcium 7.2 mg/dL (1.8 mmol/L) with tingling lips
7.临床护理

答案: C · 乳酸升高表明组织灌注不良、风险更高

为什么是这个答案

组织灌注不良时乳酸会升高。脓毒症中乳酸高提示病情更重，并用于指导液体复苏。

答案

C · 乳酸升高表明组织灌注不良、风险更高
8.临床护理

答案: C · 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

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

答案: B · Compression duplex ultrasound

为什么是这个答案

Compression ultrasound shows whether a deep vein is compressible and whether flow is normal; a vein containing clot does not compress. A low clinical probability with a negative D-dimer can rule out DVT without imaging.

答案

B · Compression duplex ultrasound
10.内外科护理：心血管与呼吸

答案: C · A catheter-related deep vein thrombosis

为什么是这个答案

Upper-limb DVT is a recognised complication of PICCs and other central lines. Arm swelling, pain and distended veins should be reported, and an ultrasound arranged. The line is not flushed forcefully, and treatment usually involves anticoagulation.

答案

C · A catheter-related deep vein thrombosis
11.内外科护理：神经、内分泌与肾脏

答案: D · Heat can briefly worsen MS symptoms, which settle when they cool down

为什么是这个答案

Heat sensitivity (Uhthoff's phenomenon) is common in MS. A rise in body temperature slows conduction in demyelinated nerves and temporarily worsens symptoms. It is not a relapse, and the symptoms settle with cooling.

答案

D · Heat can briefly worsen MS symptoms, which settle when they cool down
12.内外科护理：神经、内分泌与肾脏

答案: C · 把椅子放在左侧，并向椅子方向转身

为什么是这个答案

向较强的一侧转移更安全，这样患者可以用健侧腿负重并转身。拉扯无力的手臂可引起肩关节半脱位和疼痛。应遵循物理治疗师的建议并使用合适的辅助器具。

答案

C · 把椅子放在左侧，并向椅子方向转身
13.内外科护理：消化、围手术期与肿瘤

答案: B · Stop it about 5 days before and check the INR

为什么是这个答案

Warfarin is usually stopped about 5 days before such surgery, and the INR is checked beforehand. Patients at high clotting risk may be given bridging therapy with a heparin, as planned by the team.

答案

B · Stop it about 5 days before and check the INR
14.内外科护理：消化、围手术期与肿瘤

答案: A · 丹曲林

为什么是这个答案

恶性高热的治疗包括停用触发药物、用 100% 氧气过度通气、静脉给予丹曲林（减少肌质网钙释放）、主动降温，以及治疗高钾血症和心律失常。琥珀酰胆碱是触发因素。

答案

A · 丹曲林

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