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 22 次，有桡动脉搏动，能遵从简单指令，但有明显的腿部骨折。该伤员被归入哪一类？

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

A nurse has a needlestick injury from a used needle. What should the nurse do first?

  1. AWash the area with soap and water
  2. BFinish the shift and report it tomorrow
  3. CScrub the area with bleach
  4. DSqueeze the wound hard and suck it
3.感染控制与患者安全中等

Which patient has the highest risk of a burn from a heating pad?

  1. AA patient recovering from a cold
  2. BA patient with diabetic peripheral neuropathy
  3. CA healthy young adult with a strained muscle
  4. DA patient with a sprained wrist who is fully alert
4.感染控制与患者安全困难

Over a few hours, the emergency department sees many previously healthy people with the same unusual severe symptoms. What should the nurse do?

  1. ASend the patients home quickly to avoid crowding the emergency department
  2. BReport it to infection prevention and public health authorities promptly
  3. CTell only the patients’ families about the pattern
  4. DTreat each patient and wait to see if more arrive next week
5.实验室检查值与电解质中等

A patient with recurrent gout starts allopurinol. Which laboratory result shows that the treatment is achieving its goal?

  1. AA rising serum calcium
  2. BA falling serum potassium
  3. CA falling serum uric acid
  4. DA rising white cell count
6.实验室检查值与电解质困难

哪种结果模式符合 SIADH？

  1. A钠正常，尿液非常稀
  2. B血清钠高、血清渗透压高、尿液非常稀
  3. C血清钠低、血清渗透压低、尿液浓缩
  4. D血清钠低、血清渗透压高、尿液稀
7.临床护理中等

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

  1. ABradycardia and drowsiness
  2. BHair loss and weight gain
  3. CTremor and a fast heart rate
  4. DConstipation and urinary retention
8.临床护理困难

Why should chronic hypernatraemia be corrected gradually?

  1. ASlow correction is only needed in children
  2. BFast correction causes osmotic demyelination from swelling of the kidneys
  3. CFast correction causes severe hyperkalaemia
  4. DLowering the sodium too fast can cause cerebral oedema
9.内外科护理：心血管与呼吸中等

A patient with heart failure starts dapagliflozin, an SGLT2 inhibitor. Which teaching is most relevant?

  1. AExpect the urine to turn bright orange and stain underwear and clothes
  2. BKeep the genital area clean, as fungal infections are more common
  3. CAvoid drinking any fluids at all for the first week of treatment
  4. DTake an extra dose if the ankles swell
10.内外科护理：心血管与呼吸困难

A patient who has had a total laryngectomy becomes breathless and needs oxygen. How should it be given?

  1. AVia a mask or humidified device over the neck stoma
  2. BVia nasal cannula at 2 L/min
  3. CVia a non-rebreather mask over the mouth only
  4. DVia a standard face mask over the nose and mouth
11.内外科护理：神经、内分泌与肾脏中等

Which finding most suggests fluid overload in a patient with chronic kidney disease?

  1. AA dry mouth and a low blood pressure when standing
  2. BDark yellow urine and thirst
  3. CA weight loss of 1 kg (2.2 lb) after a hot day
  4. DA weight gain of 2 kg (4.4 lb) in two days with ankle swelling
12.内外科护理：神经、内分泌与肾脏困难

A patient with myasthenia gravis is admitted with pneumonia. Which newly prescribed antibiotic should the nurse question?

  1. ABenzylpenicillin
  2. BAmoxicillin
  3. CCeftriaxone
  4. DGentamicin
13.内外科护理：消化、围手术期与肿瘤中等

A patient with a new colostomy asks what to eat at home. Which advice is most appropriate?

  1. AAvoid all fruit and vegetables for the rest of their life
  2. BEat a normal, balanced diet and introduce foods gradually
  3. CDrink as little fluid as possible to reduce output
  4. DEat only liquids until the stoma is removed
14.内外科护理：消化、围手术期与肿瘤困难

A few hours after an ERCP, a patient has severe epigastric pain radiating to the back, with vomiting. Which complication is most likely?

  1. AHepatitis B infection
  2. BBiliary colic from a new stone
  3. CPost-ERCP pancreatitis
  4. DAcute appendicitis

3溶液

1.优先排序与委派

答案: C · 黄色（延迟）

为什么是这个答案

不能行走但通过呼吸、灌注和意识状态检查的伤员为延迟（黄色）。仅有严重损伤并不会使伤员成为立即救治。

答案

C · 黄色（延迟）
2.优先排序与委派

答案: A · Wash the area with soap and water

为什么是这个答案

The wound is washed with soap and water at once. The nurse then reports the injury immediately so the source patient can be tested and post-exposure treatment considered.

答案

A · Wash the area with soap and water
3.感染控制与患者安全

答案: B · A patient with diabetic peripheral neuropathy

为什么是这个答案

Reduced sensation, as in peripheral neuropathy, prevents a person from feeling heat damage. Patients with poor sensation, poor circulation or confusion need very close monitoring if heat is used at all.

答案

B · A patient with diabetic peripheral neuropathy
4.感染控制与患者安全

答案: B · Report it to infection prevention and public health authorities promptly

为什么是这个答案

Clusters of similar unusual illness can signal an outbreak or bioterrorism. Early reporting allows public health to investigate, guide precautions and treatment, and protect the community.

答案

B · Report it to infection prevention and public health authorities promptly
5.实验室检查值与电解质

答案: C · A falling serum uric acid

为什么是这个答案

Allopurinol reduces uric acid production by blocking xanthine oxidase. Over time, a lower serum uric acid reduces gout attacks and dissolves urate crystals. Kidney function is checked, and a rash must be reported because of rare severe skin reactions.核对依据: Gout · StatPearls (NCBI Bookshelf) (2026)

答案

C · A falling serum uric acid
6.实验室检查值与电解质

答案: C · 血清钠低、血清渗透压低、尿液浓缩

为什么是这个答案

抗利尿激素过多导致水潴留，稀释血液（钠和渗透压低），而尿液反常地浓缩。钠高伴尿液非常稀是尿崩症的模式。核对依据: Syndrome of inappropriate antidiuretic hormone secretion · MedlinePlus (NIH) (2025)

答案

C · 血清钠低、血清渗透压低、尿液浓缩
7.临床护理

答案: C · 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

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

答案: D · Lowering the sodium too fast can cause cerebral oedema

为什么是这个答案

In chronic hypernatraemia, brain cells adapt by holding extra solutes. If sodium falls too quickly, water moves into brain cells and causes cerebral oedema, so correction is controlled.

答案

D · Lowering the sodium too fast can cause cerebral oedema
9.内外科护理：心血管与呼吸

答案: B · Keep the genital area clean, as fungal infections are more common

为什么是这个答案

SGLT2 inhibitors increase glucose loss in the urine, raising the risk of genital thrush and urinary infections. They also cause mild diuresis, and in people with diabetes there is a rare risk of ketoacidosis, so they are paused during acute illness as advised. They improve outcomes in heart failure.

答案

B · Keep the genital area clean, as fungal infections are more common
10.内外科护理：心血管与呼吸

答案: A · Via a mask or humidified device over the neck stoma

为什么是这个答案

A total laryngectomy separates the trachea from the upper airway, so the patient breathes only through the neck stoma. Oxygen and any rescue breaths must be given via the stoma. These patients are "neck breathers" and often carry an alert card.

答案

A · Via a mask or humidified device over the neck stoma
11.内外科护理：神经、内分泌与肾脏

答案: D · A weight gain of 2 kg (4.4 lb) in two days with ankle swelling

为什么是这个答案

Rapid weight gain reflects fluid retention. Oedema, breathlessness, crackles in the lungs and a raised blood pressure are other signs. Daily weights are a simple and reliable way to track fluid balance.

答案

D · A weight gain of 2 kg (4.4 lb) in two days with ankle swelling
12.内外科护理：神经、内分泌与肾脏

答案: D · Gentamicin

为什么是这个答案

Aminoglycosides such as gentamicin can impair neuromuscular transmission and trigger a myasthenic crisis. Fluoroquinolones, magnesium and some other drugs carry similar warnings. The nurse checks with the prescriber before giving it.

答案

D · Gentamicin
13.内外科护理：消化、围手术期与肿瘤

答案: B · Eat a normal, balanced diet and introduce foods gradually

为什么是这个答案

People with a colostomy can usually eat a normal diet. Foods are reintroduced gradually to see how each one affects gas, odour and output, and regular meals and fluids help.

答案

B · Eat a normal, balanced diet and introduce foods gradually
14.内外科护理：消化、围手术期与肿瘤

答案: C · Post-ERCP pancreatitis

为什么是这个答案

Pancreatitis is the most common serious complication of ERCP. Severe epigastric pain radiating to the back with raised amylase or lipase suggests it; management includes analgesia, IV fluids and close monitoring.

答案

C · Post-ERCP pancreatitis

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