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 at 35 weeks of pregnancy with high blood pressure calls the clinic. Which symptom needs urgent assessment?

  1. AMild ankle swelling at the end of the day
  2. BNeeding to pass urine more often
  3. CBackache after a long walk
  4. DA severe headache with blurred vision
2.优先排序与委派困难

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

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

A patient with a fever and a cough arrives in a crowded clinic waiting room. What should the nurse do?

  1. ADo nothing until the patient is seen by the provider
  2. BGive the patient a mask and seat them apart from others
  3. CGive everyone else in the waiting room a mask instead
  4. DAsk the patient to wait outside in the car park
4.感染控制与患者安全困难

A nurse teaches new parents how to cope with an infant’s crying. Which statement shows a need for further teaching?

  1. A“I can call a friend or family member to help when I am tired.”
  2. B“I will check whether he is hungry, wet or too warm.”
  3. C“If he won’t stop crying, a quick shake will get his attention.”
  4. D“If I get frustrated, I will put him safely in the crib and take a short break.”
5.实验室检查值与电解质中等

一名服用呋塞米的患者钾为 2.9 mEq/L。护士预期会出现哪项发现？

  1. A肌肉无力和腿部抽筋
  2. B心电图上 T 波高尖
  3. C口周麻刺感，Chvostek 征阳性
  4. D肠道过度活跃引起的腹泻和腹部绞痛
6.实验室检查值与电解质困难

The nurse teaches a patient with thrombocytopenia (platelets 25 × 10³/µL) about home safety. Which statement shows a need for further teaching?

  1. A"I'll take aspirin if I get a headache"
  2. B"I'll use a soft-bristled toothbrush"
  3. C"I'll blow my nose gently, not forcefully"
  4. D"I'll use an electric razor to shave"
7.临床护理中等

A dying patient can no longer drink and has a dry mouth. What is the most appropriate nursing care?

  1. AInserting a nasogastric tube for fluids
  2. BFrequent mouth care that keeps the lips and mouth moist
  3. CStarting a fast intravenous infusion to correct the dryness
  4. DLeaving the mouth alone to avoid disturbing them
8.临床护理困难

一名头部外伤患者出现血压升高、心率减慢和呼吸不规则。这提示：

  1. A隐匿性内出血引起的低血容量性休克
  2. B脓毒症
  3. C惊恐发作
  4. D颅内压增高（库欣三联征）
9.内外科护理：心血管与呼吸中等

Why is pyridoxine (vitamin B6) often given with isoniazid?

  1. ATo prevent peripheral neuropathy
  2. BTo prevent orange discolouration of urine
  3. CTo prevent loss of colour vision
  4. DTo prevent gout attacks
10.内外科护理：心血管与呼吸困难

一名服用阿哌沙班治疗心房颤动的患者已预约择期手术。下列哪项说法体现了正确做法？

  1. A根据出血风险和肾功能，暂停用药一段设定的时间
  2. B始终继续服用到手术当天早晨
  3. C停药后用口服维生素 K 逆转
  4. D术前两周停药并改用华法林
11.内外科护理：神经、内分泌与肾脏中等

Which long-term risk should a kidney transplant recipient be taught to reduce with sun protection?

  1. AHair loss
  2. BSkin cancer
  3. CGout
  4. DKidney stones
12.内外科护理：神经、内分泌与肾脏困难

A patient with type 1 diabetes is vomiting at home. Their glucose is 12 mmol/L (216 mg/dL), and blood ketones are 3.5 mmol/L. What advice is correct?

  1. ADrink less fluid to stop the vomiting
  2. BStop insulin until the vomiting has settled
  3. CWait until the glucose is above 20 mmol/L (360 mg/dL)
  4. DSeek urgent hospital assessment for possible DKA
13.内外科护理：消化、围手术期与肿瘤中等

Which statement about fatigue during radiotherapy is correct?

  1. AIt often builds during the course and can last for weeks
  2. BIt means the radiotherapy has failed
  3. CIt occurs only after the first session and then disappears completely
  4. DIt is caused by the patient becoming radioactive
14.内外科护理：消化、围手术期与肿瘤困难

一名两个月前放置了冠状动脉支架、服用阿司匹林和氯吡格雷的患者出现黑便，现在情况稳定。对抗血小板药物，最恰当的处理是什么？

  1. A永久停用两种药物，因为任何出血都意味着它们不再安全
  2. B两种药物原样继续，并且不向团队提及出血
  3. C将两种药物的剂量加倍，因为出血意味着支架有更大的血栓风险
  4. D报告出血；由团队在心脏科的参与下决定，权衡出血与支架血栓

3溶液

1.优先排序与委派

答案: D · A severe headache with blurred vision

为什么是这个答案

A severe headache and visual changes can be signs of severe pre-eclampsia and a risk of eclampsia. Mild ankle swelling, backache and frequent urination are common in late pregnancy.

答案

D · A severe headache with blurred vision
2.优先排序与委派

答案: B · 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

B · 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: B · Give the patient a mask and seat them apart from others

为什么是这个答案

Offering a mask to people with respiratory symptoms and separating them from others reduces the spread of droplets. Tissues, hand hygiene products and waste bins are also provided.

答案

B · Give the patient a mask and seat them apart from others
4.感染控制与患者安全

答案: C · “If he won’t stop crying, a quick shake will get his attention.”

为什么是这个答案

Shaking an infant can cause bleeding in the brain, permanent disability or death. Parents are taught to put the baby down safely and step away if they feel overwhelmed, and to ask for help.

答案

C · “If he won’t stop crying, a quick shake will get his attention.”
5.实验室检查值与电解质

答案: A · 肌肉无力和腿部抽筋

为什么是这个答案

低钾引起肌肉无力、抽筋、肠蠕动减弱（便秘，甚至肠麻痹）和心律失常。T 波高尖见于高钾血症，口周麻刺感提示低钙。核对依据: Heart failure - fluids and diuretics · MedlinePlus (NIH); Low blood potassium · MedlinePlus (NIH) (2025)

答案

A · 肌肉无力和腿部抽筋
6.实验室检查值与电解质

答案: A · "I'll take aspirin if I get a headache"

为什么是这个答案

Aspirin irreversibly inhibits platelet function and raises the bleeding risk further in thrombocytopenia, so it and other NSAIDs are avoided unless prescribed. An electric razor, gentle nose blowing and a soft toothbrush reduce minor bleeding.核对依据: Bleeding and Bruising (Thrombocytopenia) and Cancer Treatment · National Cancer Institute (NIH) (2022); Aspirin · MedlinePlus (NIH) (2025)

答案

A · "I'll take aspirin if I get a headache"
7.临床护理

答案: B · Frequent mouth care that keeps the lips and mouth moist

为什么是这个答案

Regular mouth care with moist swabs, water sprays and lip balm relieves a dry mouth in the last days of life. Families can be shown how to help.

答案

B · Frequent mouth care that keeps the lips and mouth moist
8.临床护理

答案: D · 颅内压增高（库欣三联征）

为什么是这个答案

库欣三联征（高血压伴脉压增大、心动过缓和呼吸不规则）是颅内压增高的晚期征象，需要紧急处理。

答案

D · 颅内压增高（库欣三联征）
9.内外科护理：心血管与呼吸

答案: A · To prevent peripheral neuropathy

为什么是这个答案

Isoniazid increases pyridoxine loss, which can cause peripheral neuropathy, especially in people with diabetes, alcohol dependence, malnutrition or HIV. Pyridoxine prevents this. Isoniazid can also cause hepatitis. Ethambutol affects vision; pyrazinamide can cause gout.

答案

A · To prevent peripheral neuropathy
10.内外科护理：心血管与呼吸

答案: A · 根据出血风险和肾功能，暂停用药一段设定的时间

为什么是这个答案

由于 DOAC 在数天内失效，通常根据手术的出血风险和肾功能，在术前暂停一段规定的时间（常为 1–3 天）；一般不需要肝素桥接。维生素 K 不能逆转 DOAC。

答案

A · 根据出血风险和肾功能，暂停用药一段设定的时间
11.内外科护理：神经、内分泌与肾脏

答案: B · Skin cancer

为什么是这个答案

Transplant recipients have a much higher risk of skin cancers, especially squamous cell carcinoma, because of immunosuppression. Sun protection and regular skin checks are important.

答案

B · Skin cancer
12.内外科护理：神经、内分泌与肾脏

答案: D · Seek urgent hospital assessment for possible DKA

为什么是这个答案

Blood ketones above 3 mmol/L, especially with vomiting, mean a high risk of DKA, even if the glucose is only moderately raised. The patient needs urgent assessment. Insulin should not be stopped.

答案

D · Seek urgent hospital assessment for possible DKA
13.内外科护理：消化、围手术期与肿瘤

答案: A · It often builds during the course and can last for weeks

为什么是这个答案

Radiotherapy fatigue usually increases as treatment continues and may persist for weeks or months afterwards. Pacing, light exercise and good sleep and nutrition help.

答案

A · It often builds during the course and can last for weeks
14.内外科护理：消化、围手术期与肿瘤

答案: D · 报告出血；由团队在心脏科的参与下决定，权衡出血与支架血栓

为什么是这个答案

冠状动脉支架置入后早期，停用双联抗血小板治疗有很高的支架血栓和心肌梗死风险，而继续使用则增加出血。决定由医疗团队作出，最好有心脏科和消化科参与；常继续阿司匹林，第二种药物则根据出血严重程度和内镜所见短暂暂停或继续使用。

答案

D · 报告出血；由团队在心脏科的参与下决定，权衡出血与支架血栓

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