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

One hour after a vaginal birth, the nurse finds a soft, boggy uterus and heavy bleeding. What is the first action?

  1. AEncourage the patient to rest quietly
  2. BMassage the fundus
  3. COffer a meal and fluids
  4. DApply an ice pack to the perineum
2.优先排序与委派困难

一名 LPN/LVN 报告说一名稳定的患者现在出现新的胸痛。RN 应怎么做？

  1. A让护理助理做心电图并等待结果
  2. B让 LPN/LVN 处理，并在班次结束时回报
  3. C亲自评估患者并决定下一步
  4. D告诉 LPN/LVN 不经评估就给予按需使用的硝酸甘油
3.感染控制与患者安全中等

A nurse’s hands are dry and cracked from frequent hand hygiene. What is the best approach?

  1. AStop hand hygiene until the skin heals
  2. BWear gloves all day instead of cleaning the hands between patients
  3. CUse any lotion from home, whatever its contents
  4. DUse the hand lotion approved by the facility to keep the skin intact
4.感染控制与患者安全困难

某病区把浓氯化钾药瓶放在病房备用药品柜中。为什么许多安全指南建议不要这样做？

  1. A氯化钾必须始终口服
  2. B氯化钾药瓶开启后一天内就会过期
  3. C误将未稀释的浓缩液给药可使心脏停搏
  4. D氯化钾太贵，不适合作为病房常规备用药
5.实验室检查值与电解质中等

A patient taking phenazopyridine for bladder pain has bright orange urine. What should the nurse know about urine tests?

  1. AThe dye can interfere with dipstick color readings
  2. BThe color proves blood is present in the urine
  3. CThe color shows severe liver failure is present
  4. DThe drug improves the accuracy of all dipsticks
6.实验室检查值与电解质困难

A young adult has fatigue, bruising and fever. The white cell count is 85 × 10³/µL with many blasts, the hemoglobin is 7.9 g/dL (79 g/L) and the platelets are 22 × 10³/µL. What is the most likely diagnosis?

  1. AIron-deficiency anemia
  2. BPolycythemia vera
  3. CAcute viral infection
  4. DAcute leukemia
7.临床护理中等

A pressure ulcer shows full-thickness tissue loss with exposed bone. Which category (stage) is this?

  1. ACategory 2
  2. BCategory 1
  3. CCategory 3
  4. DCategory 4
8.临床护理困难

A patient admitted after a fall takes many regular medicines. Which safety step on admission helps prevent medication errors?

  1. AMedicines reconciliation against reliable sources, such as primary care records
  2. BPrescribing only the medicines that the patient can remember taking
  3. CStopping all regular medicines until the day the patient is discharged
  4. DDoubling the doses to make up for any missed while at home
9.内外科护理：心血管与呼吸中等

In heart failure, why does activation of the renin–angiotensin–aldosterone system worsen symptoms over time?

  1. AIt causes sodium and water retention and vasoconstriction
  2. BIt makes the kidneys pass too much dilute urine each day
  3. CIt lowers the blood pressure to very low levels over time
  4. DIt slows the heart rate dangerously
10.内外科护理：心血管与呼吸困难

一名呼吸困难的患者使用 15 L/min 的非重复呼吸面罩，储氧袋在每次呼吸时都完全塌陷。护士应怎么做？

  1. A取下储氧袋，因为面罩没有它也能工作
  2. B检查氧气供应和流量，使储氧袋保持充盈
  3. C不处理，因为储氧袋塌陷说明密封良好
  4. D将流量减至 2 L/min 以阻止储氧袋塌陷
11.内外科护理：神经、内分泌与肾脏中等

卒中静脉溶栓后的最初 24 小时内，哪些观察最重要？

  1. A每小时的肠鸣音和腹围
  2. B频繁的神经系统检查和血压
  3. C每小时的峰流速和血氧饱和度
  4. D仅每日体重和液体平衡
12.内外科护理：神经、内分泌与肾脏困难

Which task for a patient with a urinary catheter can the nurse delegate to a healthcare assistant (nursing assistant)?

  1. ATeaching self-catheterisation for the first time
  2. BEmptying the drainage bag and recording the volume
  3. CDeciding whether the catheter can be removed
  4. DAssessing a patient whose irrigation is not draining
13.内外科护理：消化、围手术期与肿瘤中等

Which instruction is important during bowel preparation for colonoscopy?

  1. ATake the preparation only if the bowels have not opened
  2. BAvoid all fluids for 24 hours before the test
  3. CDrink plenty of clear fluids while taking the preparation
  4. DEat a high-fibre meal the evening before the test
14.内外科护理：消化、围手术期与肿瘤困难

A nurse teaches a patient after a laparoscopic fundoplication for reflux. Which statement shows a need for further teaching?

  1. A"I should eat smaller meals for a while after the operation."
  2. B"Fizzy drinks will help me bring up wind after meals."
  3. C"I'll eat soft, moist food at first and chew it well."
  4. D"Some difficulty swallowing can happen in the early weeks."

3溶液

1.优先排序与委派

答案: B · Massage the fundus

为什么是这个答案

Uterine atony is the most common cause of postpartum hemorrhage. Fundal massage helps the uterus contract; the nurse then calls for help and gives prescribed uterotonics if bleeding continues.

答案

B · Massage the fundus
2.优先排序与委派

答案: C · 亲自评估患者并决定下一步

为什么是这个答案

当稳定的患者出现新问题时，RN 应评估患者，因为患者现在可能不稳定。然后 RN 决定干预措施和上报，可能包括心电图和处方的硝酸甘油。

答案

C · 亲自评估患者并决定下一步
3.感染控制与患者安全

答案: D · Use the hand lotion approved by the facility to keep the skin intact

为什么是这个答案

Cracked skin is harder to clean and harbors more organisms. Facility-approved lotions help keep the skin healthy without reducing the effect of hand antiseptics such as chlorhexidine.

答案

D · Use the hand lotion approved by the facility to keep the skin intact
4.感染控制与患者安全

答案: C · 误将未稀释的浓缩液给药可使心脏停搏

为什么是这个答案

浓氯化钾未经稀释或输注过快可使心脏停搏。把浓缩液从病房常规备用药中撤出，改用预混即用的输液袋，是广泛推荐的安全措施。

答案

C · 误将未稀释的浓缩液给药可使心脏停搏
5.实验室检查值与电解质

答案: A · The dye can interfere with dipstick color readings

为什么是这个答案

Phenazopyridine is a urinary analgesic dye that turns urine orange-red. It can interfere with color-based dipstick tests, so the laboratory should be told. The color is harmless, but it can stain contact lenses and clothing.核对依据: Urine - abnormal color · MedlinePlus (NIH) (2025)

答案

A · The dye can interfere with dipstick color readings
6.实验室检查值与电解质

答案: D · Acute leukemia

为什么是这个答案

Many circulating blasts with anemia and thrombocytopenia suggest acute leukemia: malignant cells crowd out normal production in the marrow. Despite the high white count, the patient has few working white cells and is at high risk of infection and bleeding.核对依据: Laboratory Evaluation of Acute Leukemia · StatPearls (NCBI Bookshelf) (2025)

答案

D · Acute leukemia
7.临床护理

答案: D · Category 4

为什么是这个答案

Category 4 involves full-thickness tissue loss with exposed bone, tendon or muscle. Category 3 is full-thickness skin loss without exposed bone or tendon. US (NPIAP) terminology calls these stages rather than categories.

答案

D · Category 4
8.临床护理

答案: A · Medicines reconciliation against reliable sources, such as primary care records

为什么是这个答案

Medicines reconciliation compares several sources to produce an accurate medication list. It finds omissions, duplications and errors, and is especially important in older people with polypharmacy.

答案

A · Medicines reconciliation against reliable sources, such as primary care records
9.内外科护理：心血管与呼吸

答案: A · It causes sodium and water retention and vasoconstriction

为什么是这个答案

Reduced cardiac output activates RAAS and the sympathetic system. Angiotensin II constricts vessels (raising afterload) and aldosterone retains sodium and water (raising preload and congestion). ACE inhibitors, ARBs, mineralocorticoid antagonists and beta-blockers block these harmful loops.

答案

A · It causes sodium and water retention and vasoconstriction
10.内外科护理：心血管与呼吸

答案: B · 检查氧气供应和流量，使储氧袋保持充盈

为什么是这个答案

储氧袋应在戴面罩之前充满，并在吸气时至少保持部分充盈。储氧袋完全塌陷意味着患者没有获得足够的氧气，可能在吸入室内空气。应检查供氧和流量，若患者仍缺氧则上报。

答案

B · 检查氧气供应和流量，使储氧袋保持充盈
11.内外科护理：神经、内分泌与肾脏

答案: B · 频繁的神经系统检查和血压

为什么是这个答案

溶栓后应频繁进行神经系统观察、血压测量和出血检查。新出现的头痛、呕吐、GCS 下降或血压升高可能提示出血。通常 24 小时内避免使用抗血小板药和抗凝药。

答案

B · 频繁的神经系统检查和血压
12.内外科护理：神经、内分泌与肾脏

答案: B · Emptying the drainage bag and recording the volume

为什么是这个答案

Emptying and recording urine volume is routine and can be delegated to trained staff. Decisions about removal, assessment of a possible blockage and first-time teaching need the registered nurse.

答案

B · Emptying the drainage bag and recording the volume
13.内外科护理：消化、围手术期与肿瘤

答案: C · Drink plenty of clear fluids while taking the preparation

为什么是这个答案

Bowel preparation causes profuse diarrhoea, which can lead to dehydration and electrolyte disturbance. Patients follow a low-residue diet, then clear fluids, and drink plenty of extra clear fluid.

答案

C · Drink plenty of clear fluids while taking the preparation
14.内外科护理：消化、围手术期与肿瘤

答案: B · "Fizzy drinks will help me bring up wind after meals."

为什么是这个答案

Fundoplication wraps the stomach around the lower oesophagus, so belching may be hard and gas bloat is common; fizzy drinks make it worse. Soft food, small meals and good chewing help while early swelling settles.

答案

B · "Fizzy drinks will help me bring up wind after meals."

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