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🚦 先看哪位患者？ · 第4课，共6课 · 6 min

先评估再行动（除非题干已经评估过了）

Assess Before You Act (Unless the Stem Already Did)

📋 考试中最诱人的错误答案，就是那个完美的干预，只是早了一步实施。护理程序有它自己的顺序。考试考的就是你是否尊重这个顺序。

📋 The most seductive wrong answer on the exam is the perfect intervention, delivered one step too early. The nursing process has an order. The exam checks whether you respect it.

💡 核心要点

题干模糊，先评估。题干数据充足且指向一个方向，就行动。永远不要选择会延误明显需要的急救行动的评估。

Vague stem, assess first. Stem full of data pointing one way, act. Never choose an assessment that delays an obviously needed emergency action.

🧠 为什么重要

护理程序是评估、诊断、计划、实施、评价（ADPIE）。当题干描述的情况模糊或不完整，并问第一个行动时，答案通常是一项评估：检查患者、测生命体征、听诊、提一个问题。当题干已经给出了评估数据、画面很清楚时，答案是一项干预。这项技能就是识别你处于哪种情况。题干说“患者诉感到头晕”时，它想要的是一项评估。题干说“患者的血压是78/40且大汗淋漓”时，它已经评估过了，它想要的是行动。而如果唯一的评估选项毫无意义或危险（在患者窒息时去查病历），就跳过它。

The nursing process is ASSESSMENT, DIAGNOSIS, PLANNING, IMPLEMENTATION, EVALUATION. When a stem describes a vague or incomplete situation and asks for the first action, the answer is usually an ASSESSMENT: check the client, take vital signs, auscultate, ask a question. When the stem already gives you the assessment data and the picture is clear, the answer is an INTERVENTION. The skill is noticing which situation you are in. A stem that says 'the client reports feeling dizzy' wants an assessment. A stem that says 'the client's blood pressure is 78/40 and he is diaphoretic' has already assessed; it wants action. And if the only assessment option is pointless or dangerous (checking a chart while a client chokes), skip it.

🏥 真实场景

🌡️ 一位肺炎患者说：“我感觉很热。”选项A：给予PRN acetaminophen。选项B：测量体温并检查有无寒战。“感觉很热”可能是房间暖和、焦虑，或者是体温正在升高。考试期望你先看再行动，所以B排第一。把题干换成“体温为39.1 °C，且医嘱规定体温超过38.5 °C时给予acetaminophen”；现在给予它就是正确的，因为评估已经完成。

🌡️ A client with pneumonia says, 'I feel hot.' Option A: give the PRN acetaminophen. Option B: take the temperature and check for chills. 'Feels hot' could be a warm room, anxiety, or a rising fever. The exam expects you to look before you act, so B is first. Change the stem to 'the temperature is 39.1 °C and acetaminophen is prescribed for a temperature over 38.5 °C'; now giving it is correct, because the assessment is done.

📌 要点总结

  • ADPIE也是一个排列答案顺序的工具ADPIE is also an answer-ordering tool
  • 题干模糊：选评估选项Vague stem: pick the assessment option
  • 题干数据丰富且指向急症：选行动Data-rich stem pointing at an emergency: pick the action

✅ 自我测试

一位术后第一天的患者说：“我感觉不对劲。”护士应先采取哪项行动？A client on the first day after surgery says, 'I don't feel right.' Which action should the nurse take first?
  1. 抬高床头并鼓励深呼吸Raise the head of the bed and encourage deep breathing
  2. 评估生命体征并询问哪里感觉不对Assess vital signs and ask what feels wrong
  3. 给予处方的PRN止痛药Administer the prescribed PRN pain medication
  4. 立即将患者的模糊主诉通知外科医生Notify the surgeon of the client's vague complaint right away

答案: B · 评估生命体征并询问哪里感觉不对

题干很模糊。评估排第一，这样下一步行动才基于数据，而不是猜测。立即将模糊的主诉通知外科医生会输，因为外科医生需要先有评估结果才能根据报告采取行动。

The stem is vague. Assessment comes first so the next action is based on data, not a guess. Notifying the surgeon of the vague complaint right away loses because the surgeon needs assessment findings first to act on the report.

一位患者的血糖为48 mg/dL，患者清醒、发抖且能吞咽。第一个行动是什么？A client's blood glucose is 48 mg/dL and the client is awake, shaky and able to swallow. What is the first action?
  1. 给予15克速效碳水化合物Give 15 grams of a fast-acting carbohydrate
  2. 打电话给医疗服务提供者Call the provider
  3. 15分钟后复查血糖，在此之前什么都不做Recheck the glucose in 15 minutes before doing anything else
  4. 评估患者的饮食史和最后一次insulin的剂量Assess the client's diet history and last insulin dose

答案: A · 给予15克速效碳水化合物

评估已经在题干中了。先治疗低血糖，然后在15分钟后复查。

The assessment is already in the stem. Treat the hypoglycemia, then recheck in 15 minutes.

考试问：对一位无法说话或咳嗽的窒息患者，首先要做什么？哪个选项是错误的，尽管它是一项评估？The exam asks what to do first for a choking client who cannot speak or cough. Which option is WRONG even though it is an assessment?
  1. 陪在患者身边直到气道通畅Stay with the client until the airway clears
  2. 查看患者的过敏史Review the client's allergy history
  3. 先给予背部叩击，然后腹部冲击Give back blows, then abdominal thrusts
  4. 呼叫帮助Call for help

答案: B · 查看患者的过敏史

查看过敏史是这里唯一的评估，而延误救命行动的评估永远不正确。患者无法说话或咳嗽，说明气道已阻塞：要行动。陪在患者身边听起来被动，但它是正确的行动：窒息的患者绝不能被单独留下。

Reviewing the allergy history is the only assessment here, and an assessment that delays a life-saving action is never correct. The client cannot speak or cough, so the airway is obstructed: act. Staying with the client may sound passive, but it is a correct action: a choking client is never left alone.

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