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 with a spinal cord injury at T4 suddenly has a severe headache, flushing above the injury and a blood pressure of 200/110 mmHg. What does the nurse do first?

  1. ASit the patient upright with the legs lowered
  2. BApply extra blankets to keep the patient warm and calm
  3. CLay the patient flat with the legs raised
  4. DGive a warm drink and recheck the blood pressure in an hour
2.优先排序与委派困难

护士应首先将哪位患者上报给快速反应小组？

  1. A一名已知高血压的患者，血压 152/94 mmHg，感觉良好
  2. B一名尿路感染患者，新出现意识模糊，呼吸频率 26 次/分，收缩压 94 mmHg
  3. C一名蜂窝织炎患者，体温 38.1 °C，其余生命体征正常
  4. D一名膝关节手术后的患者，疼痛 6/10，生命体征正常
3.感染控制与患者安全中等

In the US (EPA/OSHA) hazmat system, which level of PPE gives the highest level of protection?

  1. ALevel B
  2. BLevel A
  3. CLevel D
  4. DLevel C
4.感染控制与患者安全困难

A toddler has bruises of different ages and a burn, and the parent’s explanation does not fit the injuries. What should the nurse do?

  1. ADocument only and say nothing to anyone
  2. BConfront the parent and ask them to admit to abuse
  3. CReport the concern following child-protection (safeguarding) procedures
  4. DWait until there is clear proof of abuse before reporting anything at all
5.实验室检查值与电解质中等

静脉注射葡萄糖酸钙如何帮助重度高钾血症患者？

  1. A增加肾脏对钾的排泄
  2. B使钾从血液转移到细胞内
  3. C稳定心肌细胞膜，但不降低钾
  4. D在肠道中结合钾，使其随粪便排出
6.实验室检查值与电解质困难

A patient with ongoing hemolytic anemia has an HbA1c of 4.6%, but home glucose readings are often 180–220 mg/dL (10–12 mmol/L). What best explains the gap?

  1. AShort red cell life span lowers the HbA1c falsely
  2. BThe home glucose meter is reading falsely high
  3. CHemolysis makes the HbA1c test read too high
  4. DThe patient has true, well-controlled diabetes
7.临床护理中等

Which tool is commonly used at the bedside to screen for delirium?

  1. AThe Confusion Assessment Method (CAM)
  2. BThe Braden scale
  3. CThe Malnutrition Universal Screening Tool
  4. DThe Glasgow-Blatchford score
8.临床护理困难

一名 T4 平面脊髓损伤患者突然出现剧烈搏动性头痛、血压极高以及损伤平面以上出汗。首要措施是什么？

  1. A让患者平躺并抬高双腿以改善脑灌注
  2. B让患者坐起，检查是否膀胱充盈或导尿管堵塞
  3. C给予镇静剂，四小时后复测血压
  4. D快速静脉输注大量液体后复测血压
9.内外科护理：心血管与呼吸中等

Why does a large, rapidly forming pericardial effusion lower the blood pressure?

  1. AIt dilates the arteries throughout the body
  2. BIt makes the heart muscle contract too strongly and too fast
  3. CIt compresses the heart and stops the ventricles filling
  4. DIt causes the aortic valve to leak backwards into the ventricle
10.内外科护理：心血管与呼吸困难

A patient with a COPD exacerbation has been on NIV for two hours. They are now more drowsy, and the pH has fallen further despite a good mask fit. What should the nurse do?

  1. AContinue NIV unchanged and repeat the blood gas tomorrow morning
  2. BGive a sedative to help the patient tolerate the mask
  3. CRemove the mask and give nebulised bronchodilators only from now on
  4. DEscalate urgently for review of intubation or a ceiling of care
11.内外科护理：神经、内分泌与肾脏中等

A patient with migraine takes painkillers or triptans on most days and now has a headache almost every day. What is the likely problem?

  1. ANormal progress of migraine
  2. BA brain tumour, which is almost certain
  3. CMedication overuse headache
  4. DAn allergy to the painkillers
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. AGive another insulin dose because the meal was lost
  2. BMonitor glucose closely and tell the prescriber about the hypo risk
  3. CIgnore it, because vomiting raises blood glucose
  4. DGive the evening long-acting insulin early to balance it
13.内外科护理：消化、围手术期与肿瘤中等

哪种敷料通常适用于渗出液多的伤口？

  1. A薄的透明薄膜
  2. B藻酸盐或泡沫
  3. C水凝胶片
  4. D每周更换的干纱布
14.内外科护理：消化、围手术期与肿瘤困难

A patient who takes NSAIDs suddenly develops severe epigastric pain, a rigid abdomen and shoulder-tip pain. Which finding would most support the likely diagnosis?

  1. AFluid levels in the bladder on an ultrasound scan
  2. BTall, peaked T waves on a 12-lead ECG
  3. CFree air under the diaphragm on an erect chest X-ray
  4. DA raised serum lipase three times the upper limit

3溶液

1.优先排序与委派

答案: A · Sit the patient upright with the legs lowered

为什么是这个答案

Autonomic dysreflexia is an emergency in injuries at T6 or above. Sitting the patient up lowers the blood pressure; the nurse then looks for the trigger, most often a full bladder or constipation.

答案

A · Sit the patient upright with the legs lowered
2.优先排序与委派

答案: B · 一名尿路感染患者，新出现意识模糊，呼吸频率 26 次/分，收缩压 94 mmHg

为什么是这个答案

感染患者新出现意识模糊、呼吸频率 22 次/分或以上、收缩压 100 mmHg 或以下（qSOFA 标准），提示可能的脓毒症，恶化风险高。该患者需要紧急上报、培养和早期使用抗生素。NEWS2 等早期预警评分也给出同样的信号。其他患者是稳定的。

答案

B · 一名尿路感染患者，新出现意识模糊，呼吸频率 26 次/分，收缩压 94 mmHg
3.感染控制与患者安全

答案: B · Level A

为什么是这个答案

Level A is a fully encapsulating, vapor-tight suit with self-contained breathing apparatus, used for unknown or highly toxic agents. Level D is ordinary work clothing with minimal protection.

答案

B · Level A
4.感染控制与患者安全

答案: C · Report the concern following child-protection (safeguarding) procedures

为什么是这个答案

Injuries that do not match the history must be reported, and proof is not needed. In the US, nurses are legally mandated reporters; in the UK and many other countries, safeguarding procedures require the concern to be referred to the designated lead or children’s social care. The child’s safety is ensured and the findings are documented factually.

答案

C · Report the concern following child-protection (safeguarding) procedures
5.实验室检查值与电解质

答案: C · 稳定心肌细胞膜，但不降低钾

为什么是这个答案

钙可在数分钟内对抗高钾对心脏电活动的影响。钾仍必须通过转移入细胞（胰岛素加葡萄糖）和排出体外（结合剂、利尿剂或透析）来降低。核对依据: High potassium level · MedlinePlus (NIH) (2025)

答案

C · 稳定心肌细胞膜，但不降低钾
6.实验室检查值与电解质

答案: A · Short red cell life span lowers the HbA1c falsely

为什么是这个答案

HbA1c reflects glucose attached to hemoglobin over the red cell life span. In hemolysis, red cells are younger and have less time to bind glucose, so HbA1c is falsely low. Glucose monitoring or other markers are used instead.核对依据: The A1C Test & Diabetes · NIDDK (NIH) (2018); Hemoglobin A1C (HbA1c) Test · MedlinePlus (NIH) (2025)

答案

A · Short red cell life span lowers the HbA1c falsely
7.临床护理

答案: A · The Confusion Assessment Method (CAM)

为什么是这个答案

The CAM, and similar tools such as the 4AT, check for an acute onset or fluctuating course, inattention and disorganised thinking or altered consciousness. Early detection allows causes to be treated.

答案

A · The Confusion Assessment Method (CAM)
8.临床护理

答案: B · 让患者坐起，检查是否膀胱充盈或导尿管堵塞

为什么是这个答案

自主神经反射异常发生于 T6 及以上平面的损伤。坐起可降低血压，并且必须迅速去除诱因，最常见的是膀胱膨胀或便秘。

答案

B · 让患者坐起，检查是否膀胱充盈或导尿管堵塞
9.内外科护理：心血管与呼吸

答案: C · It compresses the heart and stops the ventricles filling

为什么是这个答案

The pericardial sac is fairly inelastic, so fluid that collects quickly raises the pressure around the heart. The ventricles cannot fill in diastole, stroke volume falls and the blood pressure drops. This is cardiac tamponade, treated by pericardiocentesis.

答案

C · It compresses the heart and stops the ventricles filling
10.内外科护理：心血管与呼吸

答案: D · Escalate urgently for review of intubation or a ceiling of care

为什么是这个答案

Worsening acidosis and consciousness on NIV mean treatment is failing. Senior review is needed to decide on intubation and ventilation or, if agreed in advance, a ceiling of care. Ideally the plan for NIV failure is documented when NIV is started. Sedation would depress breathing further.

答案

D · Escalate urgently for review of intubation or a ceiling of care
11.内外科护理：神经、内分泌与肾脏

答案: C · Medication overuse headache

为什么是这个答案

Frequent use of painkillers or triptans can cause medication overuse headache. Treatment involves withdrawing the overused drug under guidance and starting a preventive treatment if needed.

答案

C · Medication overuse headache
12.内外科护理：神经、内分泌与肾脏

答案: B · 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

B · 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 · 藻酸盐或泡沫

为什么是这个答案

藻酸盐和泡沫能吸收大量渗出液。水凝胶为干燥伤口增加水分，薄膜适合渗出液少的浅表伤口，干纱布会粘在创面上。应保护周围皮肤免受浸渍。

答案

B · 藻酸盐或泡沫
14.内外科护理：消化、围手术期与肿瘤

答案: C · Free air under the diaphragm on an erect chest X-ray

为什么是这个答案

A perforated peptic ulcer releases air into the peritoneal cavity, seen under the diaphragm on an erect chest X-ray or on CT. Shoulder-tip pain is referred from diaphragmatic irritation. The patient is kept nil by mouth, resuscitated and referred urgently to surgeons.

答案

C · Free air under the diaphragm on an erect chest X-ray

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