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 admitted with diabetic ketoacidosis. Which prescribed treatment is usually started first?

  1. AOral potassium tablets
  2. BIV isotonic fluid such as 0.9% sodium chloride
  3. CSubcutaneous long-acting insulin only, given once
  4. DA high-carbohydrate meal
2.优先排序与委派困难

A patient takes lithium. Which statement shows a need for further teaching?

  1. A“I will take ibuprofen every day for my headaches.”
  2. B“I will drink enough fluid every day.”
  3. C“I will keep my daily salt intake about the same as usual.”
  4. D“I will go for my blood tests as planned.”
3.感染控制与患者安全中等

A patient has leftover opioid tablets after surgery. Which advice about disposal is best?

  1. AReturn them to a pharmacy or an approved take-back site
  2. BLeave them in the bathroom cabinet indefinitely
  3. CKeep them in an unlocked drawer at home in case of future pain
  4. DGive them to a friend or relative who has back pain
4.感染控制与患者安全困难

A patient restrained because of violent behavior is now calm, oriented and following instructions. What should the nurse do?

  1. ARemove one restraint each day to test the patient’s behavior
  2. BRemove the restraints, because the reason for them has ended
  3. CKeep the restraints until the next provider visit
  4. DKeep the restraints until the order expires
5.实验室检查值与电解质中等

一名使用肝素输注的患者 aPTT 为 110 秒；方案目标是对照值 30 秒的 1.5–2.5 倍。护士应怎么做？

  1. A按处方给予维生素 K 并继续输注
  2. B加快输注速度，因为结果高于目标范围
  3. C遵循肝素方案，检查有无出血并通知医疗人员
  4. D保持不变，次日早晨再复查 aPTT
6.实验室检查值与电解质困难

A patient with suspected Cushing syndrome takes dexamethasone at night. The next morning, the cortisol is still high. What does this suggest?

  1. AThe result is normal, as dexamethasone raises cortisol
  2. BThe patient has primary hypothyroidism instead
  3. CCortisol is being produced without normal feedback control
  4. DThe adrenal glands are not able to produce enough cortisol
7.临床护理中等

A patient with sickle cell disease is admitted with a painful crisis. What is a key early nursing priority?

  1. ADelaying pain relief until a diagnosis is confirmed
  2. BGiving prompt, effective analgesia
  3. CApplying cold packs to the painful areas
  4. DRestricting oral fluids
8.临床护理困难

A patient with metastatic breast cancer is confused and constipated, with a corrected calcium of 3.3 mmol/L (about 13.2 mg/dL). What is usually the first treatment?

  1. AIV fluid rehydration, followed by a bisphosphonate
  2. BStrict fluid restriction to protect the kidneys
  3. CA high-calcium diet
  4. DOral calcium supplements and vitamin D
9.内外科护理：心血管与呼吸中等

一名患者出现胸骨后胸痛，心电图显示 STEMI。这通常需要什么处理？

  1. A紧急再灌注，首选直接 PCI
  2. B在作任何治疗决定前先等肌钙蛋白结果
  3. C收入院，次日早晨复查心电图
  4. D口服 β 受体阻滞剂，疼痛缓解后出院
10.内外科护理：心血管与呼吸困难

一名哮喘患者有服用阿司匹林后喘息的病史。术后疼痛被开具了布洛芬。护士应怎么做？

  1. A仅在疼痛评分高于 8/10 时给药
  2. B给药，因为布洛芬与阿司匹林无关
  3. C暂停给药并要求更换其他药物
  4. D与缓解型吸入器同时给药
11.内外科护理：神经、内分泌与肾脏中等

Why is IV calcium gluconate given in severe hyperkalaemia?

  1. AIt protects the heart from arrhythmias
  2. BIt removes potassium through the kidneys
  3. CIt moves potassium into the cells
  4. DIt binds potassium in the gut
12.内外科护理：神经、内分泌与肾脏困难

The day after a lumbar puncture, a patient has a headache that is severe when standing and almost gone when lying flat. Temperature and neck movement are normal. What is the most likely cause?

  1. APost-dural puncture headache
  2. BA subarachnoid haemorrhage
  3. CA migraine triggered by stress
  4. DBacterial meningitis from the procedure
13.内外科护理：消化、围手术期与肿瘤中等

Which monitoring is especially important for a patient receiving parenteral nutrition?

  1. ABlood glucose and signs of line infection
  2. BBowel sounds and stool colour only
  3. CPeak flow and visual acuity
  4. DPupil size and limb strength
14.内外科护理：消化、围手术期与肿瘤困难

A patient finds daily wound dressing changes very painful. What is the most effective nursing approach?

  1. AChange the dressing less often than the plan says
  2. BAvoid analgesia so the patient can report any problems during the change
  3. CGive analgesia timed so it works during the dressing change
  4. DDo the dressing quickly and give analgesia afterwards

3溶液

1.优先排序与委派

答案: B · IV isotonic fluid such as 0.9% sodium chloride

为什么是这个答案

Patients with DKA are severely dehydrated, so IV isotonic fluid is started first. IV insulin follows, with close monitoring of potassium, which can fall quickly.

答案

B · IV isotonic fluid such as 0.9% sodium chloride
2.优先排序与委派

答案: A · “I will take ibuprofen every day for my headaches.”

为什么是这个答案

NSAIDs such as ibuprofen can raise lithium levels and cause toxicity. Steady fluid and salt intake and regular blood tests help keep levels safe.

答案

A · “I will take ibuprofen every day for my headaches.”
3.感染控制与患者安全

答案: A · Return them to a pharmacy or an approved take-back site

为什么是这个答案

Returning unused opioids to a pharmacy or an approved take-back site is the preferred way to dispose of them. Leftover opioids at home can be misused or taken by children or pets.

答案

A · Return them to a pharmacy or an approved take-back site
4.感染控制与患者安全

答案: B · Remove the restraints, because the reason for them has ended

为什么是这个答案

Restraints are used only as long as needed to keep people safe. Once the patient no longer presents a danger, the restraints are removed, even if the order has not yet expired.

答案

B · Remove the restraints, because the reason for them has ended
5.实验室检查值与电解质

答案: C · 遵循肝素方案，检查有无出血并通知医疗人员

为什么是这个答案

110 秒远高于约 45–75 秒的目标，因此出血风险很高。护士应遵循肝素方案，评估有无出血并通知医疗人员。鱼精蛋白是肝素的拮抗剂；维生素 K 逆转华法林。核对依据: Partial Thromboplastin Time (PTT) Test · MedlinePlus (NIH) (2026)

答案

C · 遵循肝素方案，检查有无出血并通知医疗人员
6.实验室检查值与电解质

答案: C · Cortisol is being produced without normal feedback control

为什么是这个答案

Dexamethasone normally suppresses ACTH and lowers morning cortisol. Failure to suppress suggests autonomous cortisol excess (Cushing syndrome). Further tests then find the source, such as a pituitary or adrenal tumor.

答案

C · Cortisol is being produced without normal feedback control
7.临床护理

答案: B · Giving prompt, effective analgesia

为什么是这个答案

A sickle cell crisis needs rapid analgesia, often opioids, within a short target time, plus hydration, oxygen if hypoxic, warmth and monitoring for complications. Cold can trigger more sickling.

答案

B · Giving prompt, effective analgesia
8.临床护理

答案: A · IV fluid rehydration, followed by a bisphosphonate

为什么是这个答案

Hypercalcaemia of malignancy causes dehydration, so IV fluids are given first, followed by a bisphosphonate to reduce bone resorption. Calcium, renal function and fluid balance are monitored.

答案

A · IV fluid rehydration, followed by a bisphosphonate
9.内外科护理：心血管与呼吸

答案: A · 紧急再灌注，首选直接 PCI

为什么是这个答案

STEMI 通常反映一条冠状动脉完全闭塞。需要尽快紧急再灌注，首选直接 PCI（如果不能及时进行 PCI 则溶栓）；“时间就是心肌”。决策依据的是心电图和症状，而不是肌钙蛋白结果。

答案

A · 紧急再灌注，首选直接 PCI
10.内外科护理：心血管与呼吸

答案: C · 暂停给药并要求更换其他药物

为什么是这个答案

在 NSAID 加重性呼吸道疾病中，阿司匹林和其他抑制 COX-1 的 NSAID 可诱发严重支气管痉挛。有阿司匹林反应史的患者，未经专科建议不应使用其他 NSAID。常规剂量的对乙酰氨基酚一般耐受良好。

答案

C · 暂停给药并要求更换其他药物
11.内外科护理：神经、内分泌与肾脏

答案: A · It protects the heart from arrhythmias

为什么是这个答案

Calcium stabilises the cardiac cell membrane and reduces the risk of arrhythmias within minutes. It does not change the potassium level, so other treatments are needed to shift and remove potassium.

答案

A · It protects the heart from arrhythmias
12.内外科护理：神经、内分泌与肾脏

答案: A · Post-dural puncture headache

为什么是这个答案

A positional headache after a lumbar puncture, without fever or neck stiffness, fits a CSF leak. It is managed with rest, fluids, analgesia and caffeine, and an epidural blood patch if it persists. Fever or neck stiffness would suggest infection instead.

答案

A · Post-dural puncture headache
13.内外科护理：消化、围手术期与肿瘤

答案: A · Blood glucose and signs of line infection

为什么是这个答案

PN can cause hyperglycaemia and electrolyte disturbance, and the central line is a route for bloodstream infection. Glucose, electrolytes, fluid balance, weight and temperature are monitored closely.

答案

A · Blood glucose and signs of line infection
14.内外科护理：消化、围手术期与肿瘤

答案: C · Give analgesia timed so it works during the dressing change

为什么是这个答案

Procedural pain is best managed by giving analgesia so its peak effect matches the procedure. Non-adherent dressings, soaking adherent dressings and allowing the patient to call pauses also help.

答案

C · Give analgesia timed so it works during the dressing change

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