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

一名护理助理报告说某患者的血压是 168/98 mmHg（早些时候是 130/80），且患者头痛。RN 应怎么做？

  1. A评估患者，复测血压，并寻找症状
  2. B让助理一小时后复测血压
  3. C记录该数值，继续发药
  4. D让助理现在就给予按需使用的降压药
2.优先排序与委派困难

Two weeks after birth, a mother says she hears voices telling her the baby is evil. What is the priority?

  1. ALeave her alone with the baby to bond
  2. BKeep the mother and baby safe and arrange urgent psychiatric care
  3. CAdvise more sleep and book a routine follow-up visit for next month
  4. DReassure her that this is normal “baby blues”
3.感染控制与患者安全中等

一名护士正在为两位患者准备药物。最安全的做法是什么？

  1. A把两位患者的药放在一个杯子里，到床边再分开
  2. B为节省时间，同时准备两位患者的药物
  3. C请一位患者把药递给另一位患者
  4. D一次只为一名患者准备并给药
4.感染控制与患者安全困难

The laboratory reports that a blood sample labeled with one patient’s name has a blood group different from that patient’s previous result. What is the most likely problem and response?

  1. AA wrong-patient sample, so the test is repeated and the event reported
  2. BA normal change in the patient’s blood group over the years since the last test
  3. CA laboratory machine fault, so no action is needed
  4. DThe previous result was wrong, so it is deleted
5.实验室检查值与电解质中等

一名患者的血小板计数为 18 × 10³/µL。哪项护理措施是恰当的？

  1. A为准确起见，每四小时经直肠测体温
  2. B鼓励每天使用牙线两次，并用锋利的剃刀刮胡子
  3. C患者头痛时给予处方的阿司匹林
  4. D使用软毛牙刷、电动剃须刀，不做肌内注射
6.实验室检查值与电解质困难

A patient's AST is about twice the ALT, both moderately raised, and the GGT is high. Which cause is most likely?

  1. AAcute myocardial infarction
  2. BGallstone blocking the bile duct
  3. CAcute viral hepatitis A
  4. DAlcohol-related liver disease
7.临床护理中等

Which mask is required for staff during an aerosol-generating procedure on a patient with a respiratory infection spread by aerosols?

  1. ANo mask, as long as gloves are worn
  2. BA cloth face covering
  3. CA fit-tested respirator mask (such as FFP3 or N95)
  4. DA standard fluid-repellent surgical mask with a visor
8.临床护理困难

How should pain be assessed in a patient with advanced dementia who cannot describe it?

  1. AWith an observational pain tool that scores facial expression, behaviour and body language
  2. BBy asking the patient to rate their pain on a numerical scale from 0 to 10
  3. CBy checking the blood pressure only
  4. DBy assuming the patient has no pain unless they are crying out or calling for help
9.内外科护理：心血管与呼吸中等

什么是射血分数？

  1. A心脏每分钟泵出的血量
  2. B每次心搏射出的心室血量所占的百分比
  3. C每次心跳泵出的血量
  4. D舒张期充盈末期左心室内的压力
10.内外科护理：心血管与呼吸困难

After a car crash, a patient is severely breathless with absent breath sounds on the right, a deviated trachea, distended neck veins and BP 76/40 mmHg. What is the immediate management?

  1. AA chest X-ray to confirm the diagnosis before any treatment
  2. BInsertion of a urinary catheter to monitor output
  3. CUrgent needle or finger decompression of the right chest
  4. DLying the patient flat with the legs raised
11.内外科护理：神经、内分泌与肾脏中等

An 80-year-old with angina is diagnosed with hypothyroidism. How is levothyroxine usually started?

  1. AAt a full dose from the first day
  2. BOnly after the angina has been cured
  3. CAt a low dose, increased slowly
  4. DAs a single large weekly injection
12.内外科护理：神经、内分泌与肾脏困难

Six weeks after a kidney transplant, a patient has a fever, tenderness over the graft, less urine and a rising creatinine. What is most likely?

  1. AA normal finding as the kidney settles in
  2. BA side effect of sun exposure
  3. CAcute rejection, needing urgent transplant team review
  4. DDehydration that needs only more oral fluids and rest
13.内外科护理：消化、围手术期与肿瘤中等

Which advice may help reduce the risk of a parastomal hernia after stoma surgery?

  1. ADo intensive sit-ups from the first week
  2. BKeep the stoma bag as full as possible
  3. CAvoid heavy lifting early on and use support garments as advised
  4. DStrain hard on the toilet each day to strengthen the abdominal muscles
14.内外科护理：消化、围手术期与肿瘤困难

A patient with a permanent pacemaker is booked for surgery using monopolar diathermy. Why must the team know?

  1. AThe pacemaker will always be removed during surgery
  2. BThe patient cannot have any anaesthetic at all
  3. CPacemakers stop all bleeding during surgery
  4. DDiathermy can interfere with the pacemaker's function

3溶液

1.优先排序与委派

答案: A · 评估患者，复测血压，并寻找症状

为什么是这个答案

血压突然升高并伴有头痛是 RN 必须评估的变化。等待一小时会延误护理，而辅助人员不发药，也不决定治疗。

答案

A · 评估患者，复测血压，并寻找症状
2.优先排序与委派

答案: B · Keep the mother and baby safe and arrange urgent psychiatric care

为什么是这个答案

Hallucinations and delusions after birth suggest postpartum psychosis, a psychiatric emergency with risk to mother and baby. Safety and urgent specialist care are the priorities.

答案

B · Keep the mother and baby safe and arrange urgent psychiatric care
3.感染控制与患者安全

答案: D · 一次只为一名患者准备并给药

为什么是这个答案

在床边一次只为一名患者准备、核对和给药，可减少患者错误。把药物混在一起会使差错更容易发生。

答案

D · 一次只为一名患者准备并给药
4.感染控制与患者安全

答案: A · A wrong-patient sample, so the test is repeated and the event reported

为什么是这个答案

A different blood group strongly suggests the sample came from another patient. A new sample is taken with careful bedside identification and labeling, and the event is reported as a serious near miss.

答案

A · A wrong-patient sample, so the test is repeated and the event reported
5.实验室检查值与电解质

答案: D · 使用软毛牙刷、电动剃须刀，不做肌内注射

为什么是这个答案

严重血小板减少会因轻微外伤而出血。出血预防措施包括使用软毛牙刷、电动剃须刀，不做肌内注射或直肠操作，并避免使用阿司匹林和非甾体抗炎药。核对依据: Bleeding and Bruising (Thrombocytopenia) and Cancer Treatment · National Cancer Institute (NIH) (2022); Platelet Tests · MedlinePlus (NIH) (2024)

答案

D · 使用软毛牙刷、电动剃须刀，不做肌内注射
6.实验室检查值与电解质

答案: D · Alcohol-related liver disease

为什么是这个答案

An AST:ALT ratio of about 2:1 or more with a high GGT is typical of alcohol-related liver disease. In acute viral hepatitis ALT is usually higher than AST and often very high; bile-duct obstruction mainly raises ALP.

答案

D · Alcohol-related liver disease
7.临床护理

答案: C · A fit-tested respirator mask (such as FFP3 or N95)

为什么是这个答案

Aerosol-generating procedures, such as intubation, release small infectious particles. Respirators that are fit-tested protect the wearer, while surgical masks mainly protect against droplets.

答案

C · A fit-tested respirator mask (such as FFP3 or N95)
8.临床护理

答案: A · With an observational pain tool that scores facial expression, behaviour and body language

为什么是这个答案

Observational tools such as PAINAD or the Abbey Pain Scale help assess pain in people who cannot self-report. Family and carers can describe changes in usual behaviour.

答案

A · With an observational pain tool that scores facial expression, behaviour and body language
9.内外科护理：心血管与呼吸

答案: B · 每次心搏射出的心室血量所占的百分比

为什么是这个答案

射血分数 = 每搏量 ÷ 舒张末期容积，正常约为 50–70%。射血分数降低的心力衰竭通常定义为 40% 或更低。心输出量是每分钟的容量，每搏量是每次心搏的容量。

答案

B · 每次心搏射出的心室血量所占的百分比
10.内外科护理：心血管与呼吸

答案: C · Urgent needle or finger decompression of the right chest

为什么是这个答案

These signs indicate a tension pneumothorax, which causes obstructive shock. It is decompressed immediately (needle or finger thoracostomy) without waiting for an X-ray, followed by a chest drain. The nurse gives high-flow oxygen and calls for senior help.

答案

C · Urgent needle or finger decompression of the right chest
11.内外科护理：神经、内分泌与肾脏

答案: C · At a low dose, increased slowly

为什么是这个答案

Levothyroxine raises metabolic rate and myocardial oxygen demand. In older people and those with heart disease, a low starting dose that is increased gradually reduces the risk of angina and arrhythmias.

答案

C · At a low dose, increased slowly
12.内外科护理：神经、内分泌与肾脏

答案: C · Acute rejection, needing urgent transplant team review

为什么是这个答案

Fever, graft tenderness, falling urine output and rising creatinine suggest acute rejection, although infection must also be ruled out. Early treatment, often with high-dose steroids, can save the graft, so the transplant team is contacted urgently.

答案

C · Acute rejection, needing urgent transplant team review
13.内外科护理：消化、围手术期与肿瘤

答案: C · Avoid heavy lifting early on and use support garments as advised

为什么是这个答案

Avoiding heavy lifting in the early months, supporting the abdomen when coughing, gentle core exercises as advised by the stoma team and a healthy weight may reduce risk.

答案

C · Avoid heavy lifting early on and use support garments as advised
14.内外科护理：消化、围手术期与肿瘤

答案: D · Diathermy can interfere with the pacemaker's function

为什么是这个答案

Electrical interference from monopolar diathermy can inhibit or reprogram pacemakers and defibrillators. The team plans ahead, for example using bipolar diathermy, placing the plate carefully or having the device checked.

答案

D · Diathermy can interfere with the pacemaker's function

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