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

一名生命体征正常、病情稳定的成人手上有一处需要缝合的伤口，别无其他问题。哪个 ESI 级别合适？

  1. A4 级
  2. B2 级
  3. C3 级
  4. D5 级
2.优先排序与委派困难

Which assignment by the charge nurse should be changed?

  1. AA nursing assistant is assigned to help several stable patients with their meals
  2. BAn LPN/LVN is assigned to give oral medications to stable patients
  3. CAn LPN/LVN is assigned to admit a new patient from the emergency department
  4. DAn RN is assigned to a patient receiving a blood transfusion
3.感染控制与患者安全中等

A nurse gives part of a dose of an opioid from a vial and must discard the rest. What is correct?

  1. ADiscard it in front of a second licensed (registered) nurse, who witnesses and documents it
  2. BKeep the rest for the patient’s next dose
  3. CReturn the rest to the patient’s medication drawer
  4. DDiscard it alone in the sink and document the amount wasted later in the shift
4.感染控制与患者安全困难

A patient on an anticoagulant falls and hits their head but says they feel fine. What should the nurse do?

  1. ANotify the provider and start neurological observations, because a brain bleed may develop
  2. BGive the next anticoagulant dose early to prevent clots from forming after the fall
  3. CHelp the patient back to bed and do nothing more if they feel fine
  4. DWait until the next day to see if a headache develops
5.实验室检查值与电解质中等

一名服用华法林的患者开始每天大量食用羽衣甘蓝和菠菜。INR 已下降。哪项建议最恰当？

  1. A不告诉开医嘱者就将华法林剂量加倍
  2. B永远不再吃绿叶蔬菜
  3. C在饮食恢复正常之前停用华法林
  4. D保持富含维生素 K 的食物摄入量每天稳定
6.实验室检查值与电解质困难

A patient's bedside glucose meter shows "HI" (above its measuring range). The patient is drowsy. What should the nurse do?

  1. AGive oral glucose in case the reading is wrong and the patient is low
  2. BRecord "HI" and repeat the meter test at the next scheduled time
  3. CAssume the meter is broken and give the usual insulin dose
  4. DSend a venous sample to the lab and inform the provider at once
7.临床护理中等

Which blood results are typical of Addison's disease (primary adrenal insufficiency)?

  1. AHigh glucose and high calcium
  2. BLow sodium and high potassium
  3. CHigh sodium and low potassium
  4. DLow haemoglobin and high platelets
8.临床护理困难

A nurse notices that a wrong dose of a drug was prepared but was caught before it was given. What should be done?

  1. ASay nothing, because no harm reached the patient
  2. BReport it as a near miss through the incident reporting system
  3. CDiscipline the nurse who prepared it on the spot in front of colleagues
  4. DTell only the patient's family
9.内外科护理：心血管与呼吸中等

A patient on theophylline develops nausea, vomiting, a fast heart rate and restlessness. What should the nurse suspect?

  1. AAn expected sign that the drug is working
  2. BTheophylline toxicity
  3. CHypoglycaemia caused by the drug
  4. DA theophylline allergy causing a rash
10.内外科护理：心血管与呼吸困难

为什么高流量氧疗要使用湿化？

  1. A湿化的气体每升携带的氧气比干燥气体多
  2. B水蒸气可滤除氧气供应中的细菌
  3. C湿化可防止氧中毒的发生
  4. D高流量的干燥气体会使气道干燥，分泌物变稠
11.内外科护理：神经、内分泌与肾脏中等

After pressing the plunger of an insulin pen, what should the patient do?

  1. AInject a second dose straight away to be sure
  2. BKeep the needle in the skin for about 10 seconds
  3. CLeave the needle on the pen for the next injection
  4. DPull the needle out at once and rub the site firmly
12.内外科护理：神经、内分泌与肾脏困难

A patient had rapid-acting insulin before lunch, then vomited the meal 15 minutes later. What should the nurse do?

  1. AIgnore it, because vomiting raises blood glucose
  2. BGive the evening long-acting insulin early to balance it
  3. CGive another insulin dose because the meal was lost
  4. DMonitor glucose closely and tell the prescriber about the hypo risk
13.内外科护理：消化、围手术期与肿瘤中等

许多化疗药物给药后，对体液采取特殊预防措施通常要持续多长时间？

  1. A整整一年
  2. B通常约 48 小时
  3. C从不需要
  4. D仅在输注期间
14.内外科护理：消化、围手术期与肿瘤困难

腹部手术后使用硬膜外镇痛的患者血压 82/48 mmHg，脉搏 70 次/分，双足温暖。已排除出血。最可能的原因是什么？

  1. A失血引起的低血容量性休克
  2. B硬膜外引起的交感神经阻滞
  3. C对局部麻醉药的过敏反应
  4. D术后心源性休克

3溶液

1.优先排序与委派

答案: A · 4 级

为什么是这个答案

对稳定的患者，ESI 3 至 5 级取决于预期的资源：两种或更多为 3 级，一种为 4 级，没有为 5 级。简单缝合算一种资源，因此这是 4 级。

答案

A · 4 级
2.优先排序与委派

答案: C · An LPN/LVN is assigned to admit a new patient from the emergency department

为什么是这个答案

Admitting a new patient includes the initial assessment and plan of care, which belong to the RN. The other assignments match each staff member’s role.

答案

C · An LPN/LVN is assigned to admit a new patient from the emergency department
3.感染控制与患者安全

答案: A · Discard it in front of a second licensed (registered) nurse, who witnesses and documents it

为什么是这个答案

Wasting controlled substances requires a witness, usually another licensed nurse, and both document the waste. This prevents and detects drug diversion.

答案

A · Discard it in front of a second licensed (registered) nurse, who witnesses and documents it
4.感染控制与患者安全

答案: A · Notify the provider and start neurological observations, because a brain bleed may develop

为什么是这个答案

Head injury in a patient on anticoagulants can cause bleeding inside the skull that shows signs later. The provider is told at once, imaging may be needed and neurological checks are done closely.

答案

A · Notify the provider and start neurological observations, because a brain bleed may develop
5.实验室检查值与电解质

答案: D · 保持富含维生素 K 的食物摄入量每天稳定

为什么是这个答案

维生素 K 拮抗华法林，因此叶类蔬菜大量增加会使 INR 降低。患者不必避免这些食物，但应保持摄入量一致，以便正确设定剂量。

答案

D · 保持富含维生素 K 的食物摄入量每天稳定
6.实验室检查值与电解质

答案: D · Send a venous sample to the lab and inform the provider at once

为什么是这个答案

"HI" means the glucose exceeds the meter's range, so the true value is unknown and may be very high, as in DKA or HHS. A laboratory sample is sent, the provider is informed promptly, and the patient is assessed for dehydration and ketones.

答案

D · Send a venous sample to the lab and inform the provider at once
7.临床护理

答案: B · Low sodium and high potassium

为什么是这个答案

Without aldosterone, the kidneys lose sodium and retain potassium. Patients may also have low blood pressure, low glucose and increased skin pigmentation.

答案

B · Low sodium and high potassium
8.临床护理

答案: B · Report it as a near miss through the incident reporting system

为什么是这个答案

Near misses are reported so that causes can be studied and systems improved. A just, open culture encourages reporting without blame.

答案

B · Report it as a near miss through the incident reporting system
9.内外科护理：心血管与呼吸

答案: B · Theophylline toxicity

为什么是这个答案

Theophylline has a narrow therapeutic window. Toxicity causes nausea, vomiting, tachycardia, arrhythmias, agitation and seizures. Levels are monitored, and many drugs and smoking status change its clearance. The nurse should hold the dose and report.

答案

B · Theophylline toxicity
10.内外科护理：心血管与呼吸

答案: D · 高流量的干燥气体会使气道干燥，分泌物变稠

为什么是这个答案

高流量干燥气体超出了鼻腔湿化的能力，导致黏膜干燥、分泌物变稠和不适。加温加湿的高流量系统可提高耐受性并帮助清除分泌物。

答案

D · 高流量的干燥气体会使气道干燥，分泌物变稠
11.内外科护理：神经、内分泌与肾脏

答案: B · Keep the needle in the skin for about 10 seconds

为什么是这个答案

Holding the needle in place for around 10 seconds (or as the manufacturer advises) lets the full dose be delivered. A new needle is used for each injection, and the site should not be massaged.

答案

B · Keep the needle in the skin for about 10 seconds
12.内外科护理：神经、内分泌与肾脏

答案: D · Monitor glucose closely and tell the prescriber about the hypo risk

为什么是这个答案

The insulin will lower glucose without the carbohydrate it was meant to cover, so a hypo is likely. The nurse checks glucose often, offers carbohydrate the patient can keep down and escalates; IV glucose may be needed.

答案

D · Monitor glucose closely and tell the prescriber about the hypo risk
13.内外科护理：消化、围手术期与肿瘤

答案: B · 通常约 48 小时

为什么是这个答案

许多细胞毒性药物在给药后的一段时间内会经尿、粪、呕吐物和其他体液排出。当地规定通常要求处理体液时戴手套和穿隔离衣约 48 小时，某些药物需要更长时间。

答案

B · 通常约 48 小时
14.内外科护理：消化、围手术期与肿瘤

答案: B · 硬膜外引起的交感神经阻滞

为什么是这个答案

硬膜外局部麻醉药可阻断交感神经传出，引起血管扩张和低血压。处理遵循硬膜外方案：评估、让患者平卧、按医嘱给予液体或血管升压药并通知麻醉医生。同时也必须始终考虑出血。

答案

B · 硬膜外引起的交感神经阻滞

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