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 arrives in the recovery room after general anesthesia. What does the nurse assess first?

  1. AAirway patency and breathing
  2. BUrine output
  3. CThe surgical dressing and the drains
  4. DThe pain score
2.优先排序与委派困难

After a cervical spinal cord injury, a patient has a blood pressure of 80/50 mmHg, a heart rate of 48/min and warm, dry skin. What is most likely?

  1. ACardiac tamponade
  2. BNeurogenic shock
  3. CSeptic shock
  4. DHypovolemic shock
3.感染控制与患者安全中等

How should the urethral meatus be cared for in a patient with an indwelling urinary catheter?

  1. ABy sliding the catheter in and out a little to clean it
  2. BWith daily bladder irrigation using an antibiotic solution through the catheter
  3. CWith antiseptic cream applied to the meatus every shift
  4. DWith routine hygiene, using soap and water during daily washing
4.感染控制与患者安全困难

A nurse teaches parents about using an infant car seat. Which statement shows a need for further teaching?

  1. A“We will install the seat in the back seat, facing the rear.”
  2. B“We will make sure the harness straps are snug against the baby’s chest.”
  3. C“We will use the car seat for every trip, even short ones.”
  4. D“We will put the rear-facing seat in the front so we can see the baby.”
5.实验室检查值与电解质中等

一名因房颤服用华法林的患者 INR 为 5.2，无出血。护士最好的措施是什么？

  1. A给予通常的剂量，一个月后复查
  2. B给予双倍剂量
  3. C建议患者从今天起不再吃绿叶蔬菜
  4. D暂停华法林剂量并通知开医嘱者
6.实验室检查值与电解质困难

An 82-year-old woman without a catheter has a urine culture growing bacteria, but no fever, urinary symptoms or change in mental state. What is the best interpretation?

  1. APyelonephritis, which needs admission and IV fluids today
  2. BAsymptomatic bacteriuria, usually not treated with antibiotics
  3. CA urinary tract infection that needs urgent IV antibiotics
  4. DContamination, so the culture must be repeated every week
7.临床护理中等

Which is a major risk factor for Clostridioides difficile infection?

  1. ARegular exercise
  2. BRecent broad-spectrum antibiotic use
  3. CA diet high in fibre and fresh fruit
  4. DTaking regular paracetamol
8.临床护理困难

Which action is most important in protecting a patient with severe neutropenia from infection?

  1. AStrict hand hygiene by everyone who has contact with the patient
  2. BTaking rectal temperatures regularly
  3. CKeeping fresh flowers and plants in the room to help the patient's mood
  4. DGiving routine intramuscular injections
9.内外科护理：心血管与呼吸中等

A patient has just started an ACE inhibitor. Which blood tests are usually checked within the first one to two weeks?

  1. ALiver enzymes and amylase
  2. BPotassium and creatinine
  3. CTroponin and creatine kinase
  4. DINR and platelet count
10.内外科护理：心血管与呼吸困难

A patient with pneumonia has a temperature of 39 °C, pain and a sinus tachycardia of 122/min. BP is normal. What is the best way to manage the heart rate?

  1. AGive IV adenosine
  2. BTreat the fever, pain and possible dehydration, then reassess
  3. CArrange urgent electrical cardioversion to restore a normal rate
  4. DGive a beta-blocker to bring the heart rate below 100/min
11.内外科护理：神经、内分泌与肾脏中等

When a patient sticks out their tongue, it points to the right. Which nerve is affected?

  1. AThe right facial nerve (VII)
  2. BThe left hypoglossal nerve (XII)
  3. CThe right hypoglossal nerve (XII)
  4. DThe left trigeminal nerve (V)
12.内外科护理：神经、内分泌与肾脏困难

一名因颈椎骨折佩戴 halo 背心的患者发生心脏骤停。必须立即备好什么？

  1. A用于剪断颅骨固定针的剪刀
  2. B插入背心下方的硬板
  3. C抬高头部和肩部的枕头
  4. D用于打开背心前部以便进行心肺复苏的工具
13.内外科护理：消化、围手术期与肿瘤中等

麻醉期间，恶性高热最早的征象通常是什么？

  1. A体温持续下降
  2. B呼气末 CO₂ 无法解释地升高
  3. C皮肤潮红，同时 CO₂ 水平下降
  4. D心率减慢、血压降低
14.内外科护理：消化、围手术期与肿瘤困难

哪条安全规则适用于长春新碱？

  1. A最好在小静脉中快速静脉推注
  2. B通常与其他脊髓药物一起鞘内给药
  3. C绝不能鞘内给药；以小袋装供静脉专用
  4. D可按开处方者喜欢的任何途径给药

3溶液

1.优先排序与委派

答案: A · Airway patency and breathing

为什么是这个答案

After anesthesia, the airway can be blocked by the tongue or secretions, and breathing may be depressed. The airway and breathing are checked first, followed by circulation and the wound.

答案

A · Airway patency and breathing
2.优先排序与委派

答案: B · Neurogenic shock

为什么是这个答案

Neurogenic shock follows loss of sympathetic tone, causing vasodilation, hypotension and bradycardia with warm skin. Hypovolemic shock usually causes a fast pulse and cool, clammy skin.

答案

B · Neurogenic shock
3.感染控制与患者安全

答案: D · With routine hygiene, using soap and water during daily washing

为什么是这个答案

Routine perineal hygiene with soap and water is recommended. Antiseptic creams and routine irrigation do not reduce infection, and moving the catheter in and out carries organisms into the bladder.

答案

D · With routine hygiene, using soap and water during daily washing
4.感染控制与患者安全

答案: D · “We will put the rear-facing seat in the front so we can see the baby.”

为什么是这个答案

A rear-facing car seat must never be placed in front of an active airbag, which can strike the seat with great force. Infants ride rear-facing in the back seat, with a snug harness, on every trip.

答案

D · “We will put the rear-facing seat in the front so we can see the baby.”
5.实验室检查值与电解质

答案: D · 暂停华法林剂量并通知开医嘱者

为什么是这个答案

INR 5.2 远高于目标，会增加出血风险。护士应暂停该剂量，检查有无出血迹象并通知开医嘱者，后者可能开较低剂量或维生素 K。核对依据: Prothrombin Time Test and INR (PT/INR) · MedlinePlus (NIH) (2024); Warfarin · MedlinePlus (NIH) (2026)

答案

D · 暂停华法林剂量并通知开医嘱者
6.实验室检查值与电解质

答案: B · Asymptomatic bacteriuria, usually not treated with antibiotics

为什么是这个答案

Asymptomatic bacteriuria is common in older adults and usually should not be treated, because treatment brings adverse effects and resistance without benefit. Exceptions include pregnancy and some urological procedures.核对依据: Asymptomatic Bacteriuria · StatPearls (NCBI Bookshelf) (2023)

答案

B · Asymptomatic bacteriuria, usually not treated with antibiotics
7.临床护理

答案: B · Recent broad-spectrum antibiotic use

为什么是这个答案

Broad-spectrum antibiotics disrupt normal gut flora, letting C. difficile overgrow. Older age, hospital stay and proton pump inhibitors also increase the risk.

答案

B · Recent broad-spectrum antibiotic use
8.临床护理

答案: A · Strict hand hygiene by everyone who has contact with the patient

为什么是这个答案

Hand hygiene is the single most effective measure to protect neutropenic patients. Rectal procedures and IM injections are avoided because they can cause mucosal or tissue injury and bleeding.

答案

A · Strict hand hygiene by everyone who has contact with the patient
9.内外科护理：心血管与呼吸

答案: B · Potassium and creatinine

为什么是这个答案

ACE inhibitors lower aldosterone, so potassium can rise, and they reduce glomerular filtration pressure, so creatinine can rise, especially with renal artery stenosis or dehydration. Baseline and early follow-up urea, electrolytes and creatinine are standard.

答案

B · Potassium and creatinine
10.内外科护理：心血管与呼吸

答案: B · Treat the fever, pain and possible dehydration, then reassess

为什么是这个答案

Sinus tachycardia is usually a physiological response to fever, pain, hypovolaemia, anxiety, hypoxia or sepsis. Treating the cause (antipyretics, analgesia, fluids, oxygen if needed) is appropriate, while watching for sepsis. Rate-slowing drugs can be harmful by masking compensation.

答案

B · Treat the fever, pain and possible dehydration, then reassess
11.内外科护理：神经、内分泌与肾脏

答案: C · The right hypoglossal nerve (XII)

为什么是这个答案

With a lower motor neuron lesion of the hypoglossal nerve, the tongue deviates towards the side of the lesion, because the healthy muscles push it across. Wasting and fasciculation of that side may also be seen.

答案

C · The right hypoglossal nerve (XII)
12.内外科护理：神经、内分泌与肾脏

答案: D · 用于打开背心前部以便进行心肺复苏的工具

为什么是这个答案

用于松开背心前部的工具应一直固定在背心上，以便在心肺复苏或气道管理时迅速打开。针孔部位需要定期护理以防感染，并需要教导患者背心下的皮肤护理。

答案

D · 用于打开背心前部以便进行心肺复苏的工具
13.内外科护理：消化、围手术期与肿瘤

答案: B · 呼气末 CO₂ 无法解释地升高

为什么是这个答案

恶性高热是对挥发性麻醉药和琥珀酰胆碱的遗传性反应。早期征象包括呼气末 CO₂ 升高、心动过速和肌肉强直（常为咬肌）；高热往往是晚期征象。治疗是停用触发药物并给予丹曲林。

答案

B · 呼气末 CO₂ 无法解释地升高
14.内外科护理：消化、围手术期与肿瘤

答案: C · 绝不能鞘内给药；以小袋装供静脉专用

为什么是这个答案

鞘内注射长春新碱几乎总是致命的。为防止给药途径错误，它被稀释在小袋中供静脉使用，标注“仅供静脉使用，其他途径给药可致命”，并与鞘内药物分开存放。

答案

C · 绝不能鞘内给药；以小袋装供静脉专用

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