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。

新题目返回课程

在打印窗口中选择“另存为 PDF”，即可在设备上保存一份副本。

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 nurse takes a telephone order from a provider. What must the nurse do?

  1. AAsk the ward clerk to take the order on the nurse’s behalf instead
  2. BWrite the order down and read it back to the provider to confirm it
  3. CRemember the order and write it in the chart at the end of the shift
  4. DCarry out the order first and ask the provider to confirm it later
2.优先排序与委派困难

经尿道前列腺切除术后持续膀胱冲洗，患者的哪项发现是非预期的，需要采取行动？

  1. A鲜红色尿液伴血块，导尿管流出量减少
  2. B淡粉色尿液，在一天中逐渐变清
  3. C尽管有导尿管，仍有想排尿的感觉
  4. D轻度膀胱痉挛，使用处方的解痉药后缓解
3.感染控制与患者安全中等

护理采取空气传播预防的患者后，N95 呼吸器应在何时摘下？

  1. A在房间内、脱手套之前
  2. B绝不摘下；整个班次都佩戴
  3. C离开房间并关上门之后
  4. D刚进入房间后立即摘下
4.感染控制与患者安全困难

A patient asks for a pain tablet. The record shows none has been given, but the patient says, “The other nurse gave me one earlier.” What should the nurse do?

  1. ACheck with the other nurse and the records before giving another dose
  2. BTell the patient they must be confused
  3. CGive half a tablet now, to be safe, and the other half later if needed
  4. DGive the tablet, because the record shows none was given
5.实验室检查值与电解质中等

A patient with sickle cell disease takes hydroxyurea. Which laboratory test is monitored regularly for an adverse effect?

  1. ASerum amylase level
  2. BSerum lithium level
  3. CComplete blood count
  4. DUrine ketone level
6.实验室检查值与电解质困难

A patient on long-term amiodarone has fatigue and weight gain. TSH is 11 mIU/L and the free T4 is low. What is the most likely explanation?

  1. ASecondary hypothyroidism from pituitary failure
  2. BAmiodarone-induced hyperthyroidism
  3. CA normal response to amiodarone needing no action
  4. DAmiodarone-induced hypothyroidism
7.临床护理中等

为什么对疑似脓毒症的患者要测定血清乳酸？

  1. A它显示患者是否有尿路感染
  2. B它测量患者的血糖
  3. C它能确定该用哪种抗生素
  4. D乳酸升高表明组织灌注不良、风险更高
8.临床护理困难

一名患者的血液检查显示血钾 6.8 mmol/L，心电图显示 T 波高尖。哪种治疗能最快地保护心脏？

  1. A口服补钾
  2. B静脉注射葡萄糖酸钙
  3. C第二天口服呋塞米片
  4. D仅采用低钾饮食
9.内外科护理：心血管与呼吸中等

Which investigation is usually used to confirm a deep vein thrombosis in the leg?

  1. AA lung function test
  2. BAn exercise ECG
  3. CCompression duplex ultrasound
  4. DA plain chest X-ray and an ECG
10.内外科护理：心血管与呼吸困难

After a faulty gas heater was found at home, a patient has headache, nausea and confusion. SpO₂ is 99% on air. What is the priority treatment?

  1. AReassurance, because the oxygen saturation is normal
  2. BParacetamol (acetaminophen) and observation only
  3. CHigh-concentration oxygen via a non-rebreather mask
  4. DOxygen at 1 L/min via nasal cannula
11.内外科护理：神经、内分泌与肾脏中等

Why are patients on haemodialysis vaccinated against hepatitis B?

  1. AHepatitis B vaccine improves the fistula flow
  2. BShared dialysis units carry a higher infection risk
  3. CThe vaccine is needed to make the dialyser work
  4. DThe vaccine lowers the potassium level
12.内外科护理：神经、内分泌与肾脏困难

An 89-year-old with stage 5 CKD and severe heart failure, who has capacity, decides not to start dialysis. What is the nurse's best response?

  1. AStop all care, because nothing more can be done
  2. BTell the patient they must start dialysis by law
  3. CRespect the decision and support symptom-focused care
  4. DAsk the family to change the patient's mind
13.内外科护理：消化、围手术期与肿瘤中等

Dysphagia that started with solids and now includes liquids, with weight loss, most suggests which cause?

  1. ASimple anxiety about swallowing tablets
  2. BA dry mouth from drinking too little water
  3. CNormal ageing of the swallowing muscles
  4. DA narrowing such as an oesophageal tumour
14.内外科护理：消化、围手术期与肿瘤困难

During radiotherapy to the chest, a patient develops pain on swallowing and is eating less. What is the most likely cause and nursing focus?

  1. AA heart attack; give aspirin and arrange an ECG
  2. BRadiation oesophagitis; analgesia, soft food and nutrition support
  3. CNormal ageing; no action needed
  4. DA stomach ulcer; give an antacid after meals only

3溶液

1.优先排序与委派

答案: B · Write the order down and read it back to the provider to confirm it

为什么是这个答案

For telephone and verbal orders, the nurse writes down the full order and reads it back so the provider can confirm it. This “read-back” prevents errors from mishearing.

答案

B · Write the order down and read it back to the provider to confirm it
2.优先排序与委派

答案: A · 鲜红色尿液伴血块，导尿管流出量减少

为什么是这个答案

鲜红色尿液伴血块提示动脉出血，并可能堵塞导尿管，导致膀胱膨胀。淡粉色尿液、尿急感和轻度痉挛在此手术后很常见。

答案

A · 鲜红色尿液伴血块，导尿管流出量减少
3.感染控制与患者安全

答案: C · 离开房间并关上门之后

为什么是这个答案

因为传染性颗粒仍留在房间的空气中，所以应在房门关闭后到房间外摘下呼吸器，随后进行手卫生。手套、护目装备和隔离衣应先脱下。

答案

C · 离开房间并关上门之后
4.感染控制与患者安全

答案: A · Check with the other nurse and the records before giving another dose

为什么是这个答案

Undocumented doses can lead to double dosing. The nurse checks with colleagues and the dispensing records, then gives the drug only once it is clear whether a dose was given.

答案

A · Check with the other nurse and the records before giving another dose
5.实验室检查值与电解质

答案: C · Complete blood count

为什么是这个答案

Hydroxyurea increases fetal hemoglobin and reduces sickling crises, but it can suppress the bone marrow. The CBC, including neutrophils and platelets, is monitored regularly, and doses are adjusted if counts fall.核对依据: Sickle cell disease · MedlinePlus (NIH) (2026)

答案

C · Complete blood count
6.实验室检查值与电解质

答案: D · Amiodarone-induced hypothyroidism

为什么是这个答案

Amiodarone is rich in iodine and can cause either hypothyroidism or hyperthyroidism. A high TSH with a low free T4 shows primary hypothyroidism, so thyroid function is monitored before and during therapy; liver tests are monitored too.核对依据: Hypothyroidism · MedlinePlus (NIH) (2024)

答案

D · Amiodarone-induced hypothyroidism
7.临床护理

答案: D · 乳酸升高表明组织灌注不良、风险更高

为什么是这个答案

组织灌注不良时乳酸会升高。脓毒症中乳酸高提示病情更重，并用于指导液体复苏。

答案

D · 乳酸升高表明组织灌注不良、风险更高
8.临床护理

答案: B · 静脉注射葡萄糖酸钙

为什么是这个答案

静脉注射钙剂可在数分钟内稳定心肌。随后用胰岛素加葡萄糖使钾转移到细胞内，再用其他措施将钾排出体外。

答案

B · 静脉注射葡萄糖酸钙
9.内外科护理：心血管与呼吸

答案: C · Compression duplex ultrasound

为什么是这个答案

Compression ultrasound shows whether a deep vein is compressible and whether flow is normal; a vein containing clot does not compress. A low clinical probability with a negative D-dimer can rule out DVT without imaging.

答案

C · Compression duplex ultrasound
10.内外科护理：心血管与呼吸

答案: C · High-concentration oxygen via a non-rebreather mask

为什么是这个答案

Carbon monoxide binds haemoglobin far more strongly than oxygen, causing tissue hypoxia, while pulse oximetry can look normal. High-concentration oxygen speeds CO removal. Carboxyhaemoglobin is measured on a blood gas, and others in the home may also be at risk.

答案

C · High-concentration oxygen via a non-rebreather mask
11.内外科护理：神经、内分泌与肾脏

答案: B · Shared dialysis units carry a higher infection risk

为什么是这个答案

Haemodialysis involves repeated vascular access in a shared unit, which raises the risk of blood-borne infection. Vaccination, screening and strict infection control protect patients and staff.

答案

B · Shared dialysis units carry a higher infection risk
12.内外科护理：神经、内分泌与肾脏

答案: C · Respect the decision and support symptom-focused care

为什么是这个答案

A competent patient can refuse dialysis. The nurse makes sure the choice is informed, respects it and supports conservative kidney management, with symptom control, advance care planning and palliative care input.

答案

C · Respect the decision and support symptom-focused care
13.内外科护理：消化、围手术期与肿瘤

答案: D · A narrowing such as an oesophageal tumour

为什么是这个答案

Progressive dysphagia, solids first then liquids, with weight loss, is typical of a mechanical obstruction such as oesophageal cancer or a stricture. It needs an urgent referral for endoscopy.

答案

D · A narrowing such as an oesophageal tumour
14.内外科护理：消化、围手术期与肿瘤

答案: B · Radiation oesophagitis; analgesia, soft food and nutrition support

为什么是这个答案

Radiotherapy to the chest can inflame the oesophagus, causing painful swallowing. Analgesia (sometimes before meals), soft moist food, nutritional supplements, dietitian input and monitoring weight are important.

答案

B · Radiation oesophagitis; analgesia, soft food and nutrition support

本内容为独立练习材料。ExamProblems 与该考试的主办机构没有隶属关系，也未获其认可，考试名称仅用于描述内容。 NCLEX®, NCLEX-RN® and NCLEX-PN® 是 the National Council of State Boards of Nursing, Inc. (NCSBN) 的商标，该机构与 ExamProblems 无关，不为其背书，也不保证其准确性。

ExamProblems · examproblems.com/courses/nclex-style-prioritization-and-delegation