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

一名护士将测量血糖的任务委派给一名受过培训的助理，却从不询问结果。缺少了委派的哪项正确原则？

  1. A适合该环境的正确任务
  2. B正确的监督与评价
  3. C适合该任务的正确人员
  4. D正确的情境
2.优先排序与委派困难

Two call lights go on at the same time. One patient has pain of 7/10 after surgery. The other is a confused patient at high risk of falls who is climbing out of bed alone. Who does the nurse go to first?

  1. AThe patient in pain after surgery
  2. BThe patient whose call light went on first
  3. CThe confused patient climbing out of bed
  4. DWhichever patient’s room is closer to the station
3.感染控制与患者安全中等

A peripheral IV site is red, warm and tender along the vein. What should the nurse do?

  1. AFlush the catheter harder to clear the vein and keep using the same site
  2. BIncrease the infusion rate to finish the bag sooner
  3. CApply a warm pack and keep using the same site
  4. DRemove the catheter and insert a new one at another site if still needed
4.感染控制与患者安全困难

A responsive 6-month-old infant is choking and cannot cry or cough. What should the rescuer do?

  1. AGive back blows and chest thrusts in turn
  2. BDo a blind finger sweep of the mouth
  3. CGive abdominal thrusts as for an adult
  4. DTurn the infant upside down and shake gently
5.实验室检查值与电解质中等

一名患者的中性粒细胞绝对计数为 0.4 × 10³/µL。哪项措施是恰当的？

  1. A与另一位正在治疗肺炎的患者同住一室
  2. B严格的手卫生、体温检查，并禁止有感染的访客
  3. C因读数更准确而经直肠测体温
  4. D把鲜花带进房间以提振患者的情绪
6.实验室检查值与电解质困难

A patient who had pituitary surgery has fatigue and cold intolerance. The free T4 is low and the TSH is low. What does this pattern suggest?

  1. ASecondary (central) hypothyroidism from pituitary failure
  2. BPrimary hypothyroidism from failure of the thyroid gland
  3. CHyperthyroidism from overactivity of the thyroid gland
  4. DNormal thyroid function with a laboratory error in T4
7.临床护理中等

哪种药物用于逆转普通肝素？

  1. A硫酸鱼精蛋白
  2. B维生素 K（植物甲萘醌）
  3. C氟马西尼
  4. D纳洛酮
8.临床护理困难

A patient taking regular ibuprofen suddenly develops severe upper abdominal pain, a rigid abdomen and becomes tachycardic. What is most likely?

  1. AIndigestion that will settle with antacids
  2. BA perforated peptic ulcer
  3. CIrritable bowel syndrome
  4. DConstipation
9.内外科护理：心血管与呼吸中等

Virchow's triad describes three factors that promote venous thrombosis. Which patient factor represents venous stasis?

  1. AAn inherited clotting disorder
  2. BImmobility after major surgery
  3. CDamage to a vein during hip surgery
  4. DTaking an oestrogen-containing pill
10.内外科护理：心血管与呼吸困难

Four surgical patients need VTE prevention. For which patient is mechanical prophylaxis alone most appropriate?

  1. AA patient after an uncomplicated knee replacement
  2. BA patient who had a brain haemorrhage two days ago
  3. CA patient with cancer having bowel surgery
  4. DAn obese patient after hip surgery
11.内外科护理：神经、内分泌与肾脏中等

Why should long-term steroid treatment not be stopped suddenly?

  1. AThe steroids build up and become toxic after they are stopped
  2. BStopping causes the blood glucose to fall sharply
  3. CThe suppressed adrenal glands cannot make enough cortisol at once
  4. DStopping suddenly makes the bones grow too quickly and then fracture
12.内外科护理：神经、内分泌与肾脏困难

A patient with CKD has a high phosphate, a low calcium and a high PTH. What does this show?

  1. APrimary hyperparathyroidism from a tumour
  2. BHypoparathyroidism after neck surgery
  3. CSecondary hyperparathyroidism from CKD
  4. DToo much vitamin D from supplements
13.内外科护理：消化、围手术期与肿瘤中等

关于轻症急性胰腺炎的喂养，下列哪项说法符合目前的指南？

  1. A患者只应接受肠外营养
  2. B患者必须禁食至少三周以让胰腺休息
  3. C在淀粉酶恢复正常之前不进食
  4. D一旦疼痛和恶心允许，可尽早恢复经口进食
14.内外科护理：消化、围手术期与肿瘤困难

一名护士把少量细胞毒性药物洒在地板上。正确的处理方法是什么？

  1. A用病房的拖把拖掉，并在污物间冲洗拖把
  2. B任其蒸发，让人们离开几分钟
  3. C使用溢出处理包，穿戴个人防护装备，清理后作为细胞毒性废物装袋并上报
  4. D用纸巾擦掉，丢进一般垃圾桶

3溶液

1.优先排序与委派

答案: B · 正确的监督与评价

为什么是这个答案

护士必须跟进、检查结果并据此采取行动。委派后不检查结果违反了监督与评价的原则。

答案

B · 正确的监督与评价
2.优先排序与委派

答案: C · The confused patient climbing out of bed

为什么是这个答案

A confused patient climbing out of bed could fall and be badly injured within moments. Pain needs prompt treatment, but the immediate safety risk comes first.

答案

C · The confused patient climbing out of bed
3.感染控制与患者安全

答案: D · Remove the catheter and insert a new one at another site if still needed

为什么是这个答案

Redness, warmth and tenderness along the vein indicate phlebitis, which can lead to infection. The catheter is removed and, if IV access is still needed, a new one is placed at a different site.

答案

D · Remove the catheter and insert a new one at another site if still needed
4.感染控制与患者安全

答案: A · Give back blows and chest thrusts in turn

为什么是这个答案

For infants under one year, the rescuer alternates sets of back blows with chest thrusts, with the head lower than the chest. Abdominal thrusts are not used in infants, and blind finger sweeps can push the object further in.

答案

A · Give back blows and chest thrusts in turn
5.实验室检查值与电解质

答案: B · 严格的手卫生、体温检查，并禁止有感染的访客

为什么是这个答案

重度中性粒细胞减少感染风险很高。手卫生、早期识别发热以及避开感染源是关键。鲜花可能携带微生物，直肠操作可损伤黏膜，肺炎的室友则是感染风险。核对依据: Low white blood cell count and cancer · MedlinePlus (NIH) (2025)

答案

B · 严格的手卫生、体温检查，并禁止有感染的访客
6.实验室检查值与电解质

答案: A · Secondary (central) hypothyroidism from pituitary failure

为什么是这个答案

In primary hypothyroidism, a low T4 causes a high TSH. A low T4 with a low or inappropriately normal TSH means the pituitary (or hypothalamus) is not producing enough TSH, so the TSH cannot be used alone to monitor treatment.核对依据: Thyroxine (T4) Test · MedlinePlus (NIH) (2024); Hypothyroidism · MedlinePlus (NIH) (2024)

答案

A · Secondary (central) hypothyroidism from pituitary failure
7.临床护理

答案: A · 硫酸鱼精蛋白

为什么是这个答案

鱼精蛋白与肝素结合并将其中和。维生素 K 用于华法林。

答案

A · 硫酸鱼精蛋白
8.临床护理

答案: B · A perforated peptic ulcer

为什么是这个答案

Sudden severe pain with a board-like abdomen suggests perforation and peritonitis. The patient needs nil by mouth, IV access, analgesia and urgent surgical review.

答案

B · A perforated peptic ulcer
9.内外科护理：心血管与呼吸

答案: B · Immobility after major surgery

为什么是这个答案

Virchow's triad is stasis of blood, vessel wall injury and hypercoagulability. Immobility, long journeys and heart failure cause stasis. Surgery and trauma injure vessel walls. Oestrogen, cancer, pregnancy and inherited thrombophilias increase coagulability.

答案

B · Immobility after major surgery
10.内外科护理：心血管与呼吸

答案: B · A patient who had a brain haemorrhage two days ago

为什么是这个答案

When bleeding risk is high, such as after recent intracranial haemorrhage, mechanical methods (intermittent pneumatic compression) are used instead of anticoagulants until it is safe. The other patients are at high VTE risk and would usually receive pharmacological prophylaxis unless contraindicated.

答案

B · A patient who had a brain haemorrhage two days ago
11.内外科护理：神经、内分泌与肾脏

答案: C · The suppressed adrenal glands cannot make enough cortisol at once

为什么是这个答案

Long-term glucocorticoids suppress ACTH, and the adrenal glands shrink. Stopping abruptly can cause adrenal insufficiency or crisis. Doses are reduced gradually so the glands can recover.

答案

C · The suppressed adrenal glands cannot make enough cortisol at once
12.内外科护理：神经、内分泌与肾脏

答案: C · Secondary hyperparathyroidism from CKD

为什么是这个答案

In CKD, phosphate retention and low active vitamin D lower calcium, so the parathyroid glands release more PTH. This secondary hyperparathyroidism weakens bone. Treatment includes phosphate control, vitamin D and sometimes calcimimetics.

答案

C · Secondary hyperparathyroidism from CKD
13.内外科护理：消化、围手术期与肿瘤

答案: D · 一旦疼痛和恶心允许，可尽早恢复经口进食

为什么是这个答案

与长时间禁食或肠外营养相比，早期经口或肠内喂养有助于维持肠屏障并减少感染。在轻症胰腺炎中，通常一旦耐受就恢复低脂饮食；不必等酶水平先恢复正常。

答案

D · 一旦疼痛和恶心允许，可尽早恢复经口进食
14.内外科护理：消化、围手术期与肿瘤

答案: C · 使用溢出处理包，穿戴个人防护装备，清理后作为细胞毒性废物装袋并上报

为什么是这个答案

细胞毒性药物溢出应使用专用的溢出处理包处理，包括手套、隔离衣、护目装备，必要时戴口罩。应控制溢出范围、吸收并由外向内清理，将废物放入有标签的细胞毒性废物袋，并上报事件。

答案

C · 使用溢出处理包，穿戴个人防护装备，清理后作为细胞毒性废物装袋并上报

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