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 START 分诊中，一名不能行走的成人每分钟呼吸 36 次。该伤员被归入哪一类？

  1. A红色（立即）
  2. B黄色（延迟）
  3. C黑色（期待观察）
  4. D绿色（轻伤）
2.优先排序与委派困难

On a cardiac step-down unit, which patient should the nurse assess first?

  1. AHeart failure, weight up 0.5 kg since yesterday, no breathlessness at rest
  2. BAtrial fibrillation on warfarin with an INR of 2.6 this morning
  3. CDay 2 after a pacemaker insertion, asking when the wound dressing will be changed
  4. DSix hours after a coronary stent, new chest pain with ST elevation on the monitor
3.感染控制与患者安全中等

A nurse wants to set up a sterile field in the morning for a procedure that will take place after lunch. What is correct?

  1. ASet it up in the morning and ask a colleague to check it once
  2. BSet it up in the morning and leave it uncovered in an empty room
  3. CSet it up just before the procedure, because a waiting field may become contaminated
  4. DSet it up in the morning and cover it with a clean towel until the procedure starts
4.感染控制与患者安全困难

In US nursing practice, which task should the RN not assign to an LPN/LVN?

  1. AA dressing change on a healing surgical wound that has no signs of infection
  2. BGiving scheduled oral antibiotics to a stable patient
  3. CThe initial admission assessment of a new patient with suspected sepsis
  4. DReinforcing hand hygiene teaching that the RN has already given
5.实验室检查值与电解质中等

哪种治疗通过使钾进入细胞内来降低血清钾？

  1. A在 10 分钟内静脉注射葡萄糖酸钙
  2. B静脉注射普通胰岛素并配合葡萄糖
  3. C口服氯化钾补充剂
  4. D静脉输注 0.45% 氯化钠
6.实验室检查值与电解质困难

一名服用噻嗪类利尿剂的患者钠 129 mEq/L，钾 3.2 mEq/L，感觉乏力。哪种解释最合适？

  1. A这些结果是肾衰竭的典型表现
  2. B利尿剂导致钠和钾丢失
  3. C患者只是静脉输液导致水过多
  4. D患者有原发性醛固酮增多症，钠高
7.临床护理中等

Which type of painkiller should a patient with liver cirrhosis usually avoid?

  1. AParacetamol (acetaminophen), given in a carefully reduced and monitored dose
  2. BHot packs applied to a painful joint
  3. CLocal anaesthetic creams
  4. DNon-steroidal anti-inflammatory drugs such as ibuprofen
8.临床护理困难

A patient with back pain develops numbness around the anus and genitals and new difficulty passing urine. Which condition should be suspected?

  1. ACauda equina syndrome
  2. BSimple muscle strain
  3. CKidney stones
  4. DConstipation
9.内外科护理：心血管与呼吸中等

When should an adult with cystic fibrosis take pancreatic enzyme capsules?

  1. AOnly at bedtime
  2. BOnly when they have diarrhoea
  3. CWith all meals and snacks that contain fat
  4. DOnce a day on waking, at least an hour before any food
10.内外科护理：心血管与呼吸困难

A conscious adult in the dining room is suddenly unable to speak, cough or breathe after a mouthful of food. What should the nurse do first?

  1. AUp to five back blows, then up to five abdominal thrusts if needed
  2. BEncourage them to drink a glass of water to wash the food down
  3. CLie them down on the floor and start chest compressions immediately
  4. DSweep blindly in the mouth with a finger
11.内外科护理：神经、内分泌与肾脏中等

一名患者卒中后出现同向性偏盲。护士起初应如何帮助？

  1. A从看得见的一侧接近，并教其转头扫视
  2. B把呼叫铃和饮品放在看不见的一侧以训练该侧
  3. C用眼罩遮盖患侧的眼睛
  4. D保持房间昏暗以减少视觉刺激
12.内外科护理：神经、内分泌与肾脏困难

A patient's corrected calcium is 1.7 mmol/L (about 6.8 mg/dL). Which ECG change is most typical?

  1. AST elevation in all leads
  2. BA shortened QT interval
  3. CTall, peaked T waves
  4. DA prolonged QT interval
13.内外科护理：消化、围手术期与肿瘤中等

Patients on immune checkpoint inhibitors may develop immune-related side effects. Which symptom should they report promptly?

  1. AMild tiredness after a busy day
  2. BNew diarrhoea or abdominal pain
  3. CA small bruise after a knock
  4. DSlight hair thinning over months
14.内外科护理：消化、围手术期与肿瘤困难

A patient's ileostomy output is 2.5 L a day. They feel tired and dizzy and are drinking large amounts of water. Which advice is usually appropriate?

  1. AStop all drinking for 24 hours
  2. BEat only fruit and fruit juice
  3. CLimit plain drinks and use an oral rehydration solution
  4. DDrink even more plain water and tea to replace the losses

3溶液

1.优先排序与委派

答案: A · 红色（立即）

为什么是这个答案

在 START 中，呼吸频率超过 30 次/分意味着伤员被标为立即（红色）。30 次或以下则继续进行灌注和意识状态检查。

答案

A · 红色（立即）
2.优先排序与委派

答案: D · Six hours after a coronary stent, new chest pain with ST elevation on the monitor

为什么是这个答案

New chest pain with ST elevation after a stent suggests the stent may have blocked, causing an acute myocardial infarction. This is an emergency; the other findings are within target or routine.

答案

D · Six hours after a coronary stent, new chest pain with ST elevation on the monitor
3.感染控制与患者安全

答案: C · Set it up just before the procedure, because a waiting field may become contaminated

为什么是这个答案

The longer a sterile field is exposed, the more likely it is to be contaminated, and an unattended field cannot be considered sterile. It is prepared just before use.

答案

C · Set it up just before the procedure, because a waiting field may become contaminated
4.感染控制与患者安全

答案: C · The initial admission assessment of a new patient with suspected sepsis

为什么是这个答案

The initial assessment of a new, potentially unstable patient is an RN responsibility. LPNs/LVNs can give routine medications, perform routine procedures and reinforce teaching for stable patients.

答案

C · The initial admission assessment of a new patient with suspected sepsis
5.实验室检查值与电解质

答案: B · 静脉注射普通胰岛素并配合葡萄糖

为什么是这个答案

胰岛素激活钠–钾泵，使钾进入细胞内；同时给予葡萄糖以预防低血糖。葡萄糖酸钙保护心脏，但不降低钾水平。核对依据: High potassium level · MedlinePlus (NIH) (2025)

答案

B · 静脉注射普通胰岛素并配合葡萄糖
6.实验室检查值与电解质

答案: B · 利尿剂导致钠和钾丢失

为什么是这个答案

噻嗪类利尿剂常引起低钠血症和低钾血症，尤其是在老年人中。护士应报告结果，开医嘱者会复核药物和电解质补充。核对依据: Thiazide Diuretics · StatPearls (NCBI Bookshelf) (2025)

答案

B · 利尿剂导致钠和钾丢失
7.临床护理

答案: D · Non-steroidal anti-inflammatory drugs such as ibuprofen

为什么是这个答案

NSAIDs increase the risk of GI bleeding and can trigger kidney failure and fluid retention in cirrhosis. Paracetamol is usually preferred at a lower, carefully chosen dose.

答案

D · Non-steroidal anti-inflammatory drugs such as ibuprofen
8.临床护理

答案: A · Cauda equina syndrome

为什么是这个答案

Saddle anaesthesia, bladder or bowel dysfunction and leg symptoms with back pain suggest cauda equina syndrome. It needs an emergency MRI and surgical review to prevent permanent loss of function.

答案

A · Cauda equina syndrome
9.内外科护理：心血管与呼吸

答案: C · With all meals and snacks that contain fat

为什么是这个答案

In CF, thick secretions block the pancreatic ducts, causing fat malabsorption and fatty stools. Enzyme capsules are taken with every meal and fat-containing snack, with the dose adjusted to fat intake. Fat-soluble vitamins (A, D, E, K) are also supplemented.

答案

C · With all meals and snacks that contain fat
10.内外科护理：心血管与呼吸

答案: A · Up to five back blows, then up to five abdominal thrusts if needed

为什么是这个答案

For a conscious adult with severe choking, current UK, European and AHA (2025) guidance teach up to five back blows, then up to five abdominal thrusts, repeated until the obstruction clears; some older courses used abdominal thrusts alone. If the person becomes unconscious, CPR is started. Blind finger sweeps can push the object further in.

答案

A · Up to five back blows, then up to five abdominal thrusts if needed
11.内外科护理：神经、内分泌与肾脏

答案: A · 从看得见的一侧接近，并教其转头扫视

为什么是这个答案

起初，把重要物品放在视力完好的一侧并从该侧接近患者，可提高安全性。随着时间推移，教患者向缺失的视野侧转头扫视。遮盖一只眼没有帮助，因为双眼丢失的是同一半视野。

答案

A · 从看得见的一侧接近，并教其转头扫视
12.内外科护理：神经、内分泌与肾脏

答案: D · A prolonged QT interval

为什么是这个答案

Hypocalcaemia prolongs the QT interval, which can lead to dangerous arrhythmias. A short QT is seen in hypercalcaemia, and peaked T waves are typical of hyperkalaemia.

答案

D · A prolonged QT interval
13.内外科护理：消化、围手术期与肿瘤

答案: B · New diarrhoea or abdominal pain

为什么是这个答案

Checkpoint inhibitors can cause immune-mediated colitis, pneumonitis, hepatitis, skin reactions and endocrine problems. Early reporting allows grading and treatment, often with corticosteroids.

答案

B · New diarrhoea or abdominal pain
14.内外科护理：消化、围手术期与肿瘤

答案: C · Limit plain drinks and use an oral rehydration solution

为什么是这个答案

In high-output stomas, hypotonic drinks increase sodium loss through the stoma. Restricting them and using a glucose–salt oral rehydration solution, with antimotility drugs as prescribed and medical review, helps correct dehydration.

答案

C · Limit plain drinks and use an oral rehydration solution

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