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 reports pain of 8/10. Before giving the prescribed as-needed analgesic, what does the nurse do first?

  1. AAsk the nursing assistant to reposition the patient
  2. BTell the patient to wait until the next scheduled dose is due in two hours
  3. CGive the strongest analgesic on the chart straight away
  4. DAssess the location, character and onset of the pain and the vital signs
2.优先排序与委派困难

Four patients arrive at the emergency department at the same time. Who should be seen first?

  1. AA young adult with a swollen, painful ankle after a fall on the stairs
  2. BAn adult with kidney stone pain of 9/10 and stable vital signs
  3. CA child with a temperature of 39 °C who is alert and drinking
  4. DAn older adult with weakness on one side that began 40 minutes ago
3.感染控制与患者安全中等

What is the main aim of purposeful hourly rounding?

  1. ATo wake the patient every hour to check orientation
  2. BTo count the patient’s medications every hour and check that none are missing
  3. CTo replace the need for a call light
  4. DTo check pain, toileting, position and personal items before the patient needs to ask
4.感染控制与患者安全困难

Shortly after a patient falls, the team holds a brief “post-fall huddle”. What is its main purpose?

  1. ATo decide which staff member was to blame for the fall
  2. BTo agree on what the team will tell the patient’s lawyer and the family
  3. CTo complete the patient’s discharge paperwork
  4. DTo find out quickly why the fall happened and change the care plan to prevent another
5.实验室检查值与电解质中等

A patient had a right mastectomy with removal of axillary lymph nodes. Where is the best place to draw blood?

  1. AThe left arm
  2. BThe right hand
  3. CThe right arm
  4. DEither arm equally
6.实验室检查值与电解质困难

A patient with blood pressure that is hard to control has a potassium of 2.9 mEq/L, a sodium of 144 mEq/L and a raised serum bicarbonate, without taking a diuretic. Which condition is most likely?

  1. APrimary adrenal insufficiency
  2. BPrimary hyperaldosteronism
  3. CCentral diabetes insipidus
  4. DSyndrome of inappropriate ADH
7.临床护理中等

Which side effects are common after high doses of salbutamol (albuterol)?

  1. AConstipation and urinary retention
  2. BHair loss and weight gain
  3. CBradycardia and drowsiness
  4. DTremor and a fast heart rate
8.临床护理困难

一名颅脑损伤患者的 GCS 从 14 分降至 10 分，一侧瞳孔变大且对光反应迟钝。护士应该怎么做？

  1. A作为神经科急症立即上报
  2. B在下一次常规观察时复查 GCS
  3. C给予镇静剂使患者平静
  4. D鼓励患者睡觉
9.内外科护理：心血管与呼吸中等

COPD 的肺康复是什么？

  1. A每六个月重复一次的肺功能检查
  2. B每年冬天在家服用一个疗程的口服类固醇和抗生素
  3. C在监督下进行的运动和教育，以减轻呼吸困难
  4. D切除肺部受损最严重区域的手术
10.内外科护理：心血管与呼吸困难

一名心力衰竭患者三天内体重增加 2.5 kg，双肺底出现新的湿啰音，现在需要垫四个枕头睡觉。血压 138/84 mmHg，未吸氧时 SpO₂ 93%。优先处理是什么？

  1. A记录体重，下周末再复查
  2. B鼓励多喝水以保护肾脏
  3. C让患者平躺以让心脏休息、降低需求
  4. D让患者坐起，全面评估并报告液体过多
11.内外科护理：神经、内分泌与肾脏中等

Which complication is a particular risk in nephrotic syndrome?

  1. ALow cholesterol
  2. BBleeding from low platelets
  3. CHypoglycaemia
  4. DVenous thrombosis
12.内外科护理：神经、内分泌与肾脏困难

A patient with a brain tumour on high-dose dexamethasone has a capillary glucose of 16 mmol/L (288 mg/dL). They have no history of diabetes. What is the best explanation?

  1. AA lab error, because steroids lower blood glucose
  2. BSteroid-induced hyperglycaemia, which needs monitoring and treatment
  3. CNormal for this patient, so no action is needed
  4. DA sign that the brain tumour has now spread to the pancreas
13.内外科护理：消化、围手术期与肿瘤中等

How should a patient use an incentive spirometer after surgery?

  1. AUse it once a day, just before going to sleep at night
  2. BBreathe quickly in and out ten times in a row
  3. CBreathe in slowly and deeply, then hold briefly
  4. DBlow out as hard and as fast as possible
14.内外科护理：消化、围手术期与肿瘤困难

A patient with a toe ulcer says the leg pain is worse at night and eases when they hang the leg over the side of the bed. What does this suggest?

  1. AVenous insufficiency
  2. BArterial insufficiency
  3. CNeuropathic itching
  4. DLymphoedema

3溶液

1.优先排序与委派

答案: D · Assess the location, character and onset of the pain and the vital signs

为什么是这个答案

Assessment comes first, because severe pain may be a sign of a new complication such as bleeding or a heart attack. The assessment also guides which analgesic is appropriate.

答案

D · Assess the location, character and onset of the pain and the vital signs
2.优先排序与委派

答案: D · An older adult with weakness on one side that began 40 minutes ago

为什么是这个答案

Sudden one-sided weakness suggests a stroke, and treatment depends on how quickly it starts. Severe kidney stone pain needs prompt pain relief, but the patient is stable.

答案

D · An older adult with weakness on one side that began 40 minutes ago
3.感染控制与患者安全

答案: D · To check pain, toileting, position and personal items before the patient needs to ask

为什么是这个答案

Regular, planned rounding that addresses pain, toileting, positioning and possessions within reach reduces falls and call-light use. The call light stays within reach as well.

答案

D · To check pain, toileting, position and personal items before the patient needs to ask
4.感染控制与患者安全

答案: D · To find out quickly why the fall happened and change the care plan to prevent another

为什么是这个答案

A post-fall huddle brings the team together soon after the fall to identify causes such as toileting, medication or footwear and to update the plan. It supports a just culture rather than blame.

答案

D · To find out quickly why the fall happened and change the care plan to prevent another
5.实验室检查值与电解质

答案: A · The left arm

为什么是这个答案

After axillary node removal, venipuncture and blood pressure readings are usually avoided on that side to reduce the risk of lymphedema and infection. The opposite arm is used whenever possible, according to policy.

答案

A · The left arm
6.实验室检查值与电解质

答案: B · Primary hyperaldosteronism

为什么是这个答案

Excess aldosterone causes sodium and water retention (hypertension), potassium loss (hypokalemia) and hydrogen ion loss (metabolic alkalosis). Adrenal insufficiency causes the opposite pattern, with low sodium and high potassium.核对依据: Primary and secondary hyperaldosteronism · MedlinePlus (NIH) (2025); Alkalosis · StatPearls (NCBI Bookshelf) (2024)

答案

B · Primary hyperaldosteronism
7.临床护理

答案: D · Tremor and a fast heart rate

为什么是这个答案

Salbutamol is a beta2-agonist and can cause tremor, tachycardia and palpitations. High doses can also lower serum potassium.

答案

D · Tremor and a fast heart rate
8.临床护理

答案: A · 作为神经科急症立即上报

为什么是这个答案

GCS 下降伴单侧瞳孔散大提示颅内压升高、可能发生脑疝。需要紧急医疗评估和影像学检查。

答案

A · 作为神经科急症立即上报
9.内外科护理：心血管与呼吸

答案: C · 在监督下进行的运动和教育，以减轻呼吸困难

为什么是这个答案

肺康复结合个体化的运动训练、教育和呼吸技巧。它可提高运动能力，减轻呼吸困难，改善生活质量，并减少住院。推荐用于因呼吸困难而活动受限的 COPD 患者以及急性加重之后。

答案

C · 在监督下进行的运动和教育，以减轻呼吸困难
10.内外科护理：心血管与呼吸

答案: D · 让患者坐起，全面评估并报告液体过多

为什么是这个答案

体重迅速增加伴湿啰音和端坐呼吸提示液体过多和心力衰竭加重。坐直可减少静脉回流并缓解呼吸。护士应完成评估（氧合趋势、液体平衡、水肿）并上报，以便开处方者调整利尿剂。补充更多液体或平躺会加重淤血。

答案

D · 让患者坐起，全面评估并报告液体过多
11.内外科护理：神经、内分泌与肾脏

答案: D · Venous thrombosis

为什么是这个答案

In nephrotic syndrome, anticoagulant proteins such as antithrombin are lost, and clotting factors made by the liver rise, so venous thrombosis is more likely. Infection and high cholesterol are other complications.

答案

D · Venous thrombosis
12.内外科护理：神经、内分泌与肾脏

答案: B · Steroid-induced hyperglycaemia, which needs monitoring and treatment

为什么是这个答案

Glucocorticoids increase glucose production and insulin resistance, so hyperglycaemia is common, often later in the day after a morning dose. Glucose is monitored regularly, and treatment may be needed. Other steroid effects include mood change and gastric irritation.

答案

B · Steroid-induced hyperglycaemia, which needs monitoring and treatment
13.内外科护理：消化、围手术期与肿瘤

答案: C · Breathe in slowly and deeply, then hold briefly

为什么是这个答案

Slow, deep inspiration with a short hold expands the alveoli and helps prevent atelectasis. It is repeated regularly while awake, together with coughing and good pain control.

答案

C · Breathe in slowly and deeply, then hold briefly
14.内外科护理：消化、围手术期与肿瘤

答案: B · Arterial insufficiency

为什么是这个答案

Rest pain eased by dependency is typical of severe peripheral arterial disease. Elevating the leg worsens pain, and compression is avoided. Vascular assessment is needed.

答案

B · Arterial insufficiency

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