2. The main source of patient data is (the patient himself).
3, the patient's psychological and social status assessment content does not include (treatment plan)
4. The best way for nurses to observe patients' condition is to talk with patients frequently and increase daily contact.
5. The patient said to the nurse, "I can't see my children and my wife, and I feel uncomfortable." Show the patient's existence (the need for love and belonging)
6. The patient has severe abdominal pain, cold limbs and shortness of breath when waiting in the outpatient department. Outpatient nurses should (arrange early treatment)
7. The indoor temperature of the operating room should be controlled at (22℃ ~ 24℃).
8, the purpose of ward ventilation, inappropriate is (inhibit the growth of bacteria)
9, in order to achieve the purpose of replacing indoor air, each ventilation time is generally (30 minutes).
10, the bed unit of patients with brain trauma after operation should be (anesthesia bed, with a rubber sheet and a sheet in the middle and upper part of the bed).
1 1. The nurse should prepare an anesthesia bed for the open fracture of the right lower limb, which should be (a single bed and a rubber plate in the middle of the bed).
12, the basis for admission procedures in the admission office is (admission ticket)
13. The first item in the patient's medical record is (temperature list).
14. Patients with "spleen rupture" need to be hospitalized for surgery, and the nurses in the inpatient department should first (quickly admit them to the hospital).
15. Patients with "spleen rupture" need to be hospitalized for surgery. Ward nurses should first (lay an anesthesia bed).
16, those who do not meet the requirements of special care (monitoring vital signs every 2 hours 1 time)
17. The medical care documents of discharged patients were not handled correctly (the diagnosis card and treatment card were sandwiched in the medical record).
18, the best way to transport patients with lumbar fractures is (flat car four-person transport method).
19. It is inappropriate for a nurse to temporarily stop infusion during the transportation when escorting a coma patient in a car accident for emergency X-ray examination.
20, nurses should assist patients with bronchial asthma attack position is (sitting).
2 1-40 knowledge points
2 1. The most suitable position for patients with hemorrhagic shock is (concave lying position).
22. After the open facial wound caused by a car accident is debrided and sutured, the posture that should be taken for admission observation is (half sitting and lying position).
23. The prone position used by nurses to assist patients with premature rupture of membranes should be (head low and feet high).
24. In order to protect the foot function of patients who need to stay in bed for a long time because of lower limb paralysis, the optional protective device is (support frame).
25, tetanus patients dressing should be (centralized burning)
26, high pressure steam sterilization pot for sterilization, pot pressure reaches the required value, should be kept (30 minutes).
27, burn ward air disinfection is the best way (filtration sterilization).
28. Use pure lactic acid to disinfect the air in the locker room. The length, width and height of the dressing room are 4m, 5m and 3m respectively, and the required lactic acid amount is (7.2ml).
29, in the fiber gastroscope disinfection, the appropriate choice of chemical disinfection method is (2% glutaraldehyde immersion).
30, the nurse should be contaminated by the patient's blood bedside table (disinfectant) to wipe clean.
3 1 sterile tweezers with a length of 16cm, when stored in its soaking container, the suitable disinfection solution depth is (8cm).
32, the nurse found in the process of nursing operation gloves are damaged, should (immediately replace gloves).
33. After aseptic packaging is opened, unused aseptic supplies should be packed according to the original crease, indicating the date and time of opening the package, and the validity period is (24h).
34. The validity period of the laid sterile tray shall not exceed (4h).
35. When putting on the sterile gloves, the mistake is (the gloves are taken out from the inside of the gloves).
36, in the infectious disease area belongs to the pollution area is (ward)
37. It is correct for nurses in infectious disease wards to take off their isolation gown (hanging in the corridor, with the cleaning face facing outward) after the middle shift.
38, oral care for coma patients don't need to prepare (suction tube).
39. In oral care for coma patients, the following mistakes occurred (after scrubbing, help patients rinse their mouths).
40, oral care, mouth opener should be (molar).
4 1-60 knowledge points
4 1, the patient's removable denture is cleaned first (in cold water).
42. The female patient stayed in bed for many days, resulting in long hair knotting and adhesion. Nurses should choose (30% ethanol) to moisten and dredge their hair.
43. Nurses should take off their clothes (the healthy side first and then the affected side) when bathing patients with left lower limb knee replacement.
44, long-term bedridden patients should focus on preventing the occurrence of pressure ulcers (lumbosacral).
45. The main characteristics of pressure ulcers in the period of blood stasis and ruddy blood are (local skin redness, swelling, heat and pain).
46. The nurse used 50% ethanol to massage the patient, with the purpose of (promoting blood circulation).
47. The appropriate time for nurses to do morning and evening care for primary care patients is (before diagnosis and treatment, after dinner).
48. The normal range of adult axillary temperature is (36.0℃ ~ 37.0℃).
49. A 36-year-old male patient was hospitalized with pneumonia. He had a fever for 2 days, and his oral temperature fluctuated from 39.3℃ to 40.0℃ every day, accompanied by obvious pulse and accelerated breathing. The patient's fever type belongs to (missed diagnosis of fever).
50, missed diagnosis of fever is common in (pneumococcal pneumonia)
5 1. It is correct to observe the body temperature of patients with high fever (every 4 hours 1 time).
52. Patient, male, 50 years old. He was admitted to hospital with a high fever, and his temperature was 39.9℃. The correct physical cooling measures are (placing ice packs on the forehead and overhead)
53, patients with self-test temperature, first throw the thermometer (below 35℃).
54. The heart rhythm is extremely irregular, with different heart rates and different heart sounds. Heart rate 102 beats/min, pulse rate 78 beats/min. This pulse belongs to (short pulse)
55, pulse measurement preferred artery is (radial artery)
56. The method for nurses to measure the pulse rate and heart rate of patients with atrial fibrillation is (two people measure the pulse rate and heart rate separately, and start and end at the same time, 1 min).
57, meningitis patients breathing is periodic, from shallow slow to deep fast, and then from deep fast to shallow slow, after a period of apnea, repeat the above process. The patient's breathing belongs to (tidal breathing)
58. Patient, male, 68 years old. He was admitted to the hospital because of cerebral hemorrhage, and now he is unconscious and paralyzed in his left limb. The correct way for nurses to measure body temperature and blood pressure is (measuring underarm temperature and blood pressure of right upper limb).
59, China residents "balanced diet pagoda" at the bottom, that is, the most basic component of residents' diet is (grain).
60, does not belong to the hospital's basic diet is (diet)
6 1-80 knowledge points
6 1, avoid meat, liver, iron-rich drugs and green vegetables. The experimental diet is (occult blood test diet)
62. The nurse instructed the patients with fecal occult blood test to eat (bean products) within the first three days of collecting specimens.
63. Patient, female, 32 years old. The doctor ordered 13 1I thyroid function examination, and the nurse instructed the patient to avoid eating (laver) during the trial.
64. The correct way to measure the insertion length of gastric tube is (from hairline to xiphoid process).
65. In order to improve the success rate of nasogastric tube intubation, key measures should be taken (when inserting 15cm, hold the patient's head and make the mandible close to the sternum handle).
66, every time for patients to inject nasal feeding liquid quantity and interval requirements are (≤200ml； or less; ≥2h)
67. After injecting a liquid diet through nasal feeding, the purpose of injecting a small amount of warm water is to (flush the stomach tube and avoid the accumulation of nasal feeding liquid).
68, in the process of gastric tube insertion, patients with nausea and vomiting, the nurse should first (pause intubation and tell patients to take a deep breath).
69. Patient, female, 30 years old. High fever is 39℃. The doctor ordered the ice pack to cool down physically. The correct location of the ice pack is (forehead)
70. Hyperthermia can (promote) or (limit) the spread of inflammation.
7 1, the nurse used a hot water bottle to keep the coma patient warm. The correct way is to wrap the hot water bottle with a towel.
72. Observe that the skin color is purplish red when irradiated by infrared rays. At this time, the nurse should (stop the irradiation immediately and protect the skin with vaseline).
73. After anal fistula surgery, patients should take hot water sitz bath (15 ~ 20 minutes).
74, 24 hours urine volume is 360ml, the patient's micturition status belongs to (oliguria).
75, the nurse should be placed for female patients indwelling catheter position is (kneeling supine position).
76. When observing the urine of patients with indwelling catheterization, the nurse found that the urine was turbid and precipitated, and should (give bladder irrigation).
77, constipation patients do a lot of enema, nurses choose enema temperature should be (39 ~ 465438 0℃).
78. Child, male, 4 years old. He was taken to hospital with pneumonia. The temperature was 39.6℃, and the doctor ordered the child to have an enema to cool down. The enema temperature is 29℃
79. Child, male, 4 years old. He was taken to hospital with pneumonia. The temperature was 39.6℃, and the doctor ordered the child to have an enema to cool down. The position that children should take when enema is (left lateral position)
80. Child, male, 4 years old. He was taken to hospital with pneumonia. The temperature was 39.6℃, and the doctor ordered the child to have an enema to cool down. The depth of insertion into anal canal during enema is (4 ~ 7 cm)
Nursing care of patients with circulatory system diseases
1-20 knowledge points
1, the anatomical position of mitral valve is (between left atrium and left ventricle)
2. The physiological function of the fluid in pericardial cavity is (lubrication).
The blood supply of the heart itself mainly comes from (coronary artery)
4. The myocardial cell with autonomy is (sinoatrial node).
5. The pacing point of normal sinus rhythm is (sinus node).
6. Under normal circumstances, the direction of ventricular depolarization is (from endocardium to epicardium)
7. Patients with chronic cardiac insufficiency of Grade II should be manifested as (dyspnea after daily activities and relief after rest).
8. The causes of left ventricular pressure overload are hypertension and aortic stenosis.
9. The most important clinical manifestation of patients with chronic left ventricular dysfunction is dyspnea.
10. The pathophysiological basis of the main clinical symptoms of right heart insufficiency is (systemic congestion).
1 1. The characteristic sign of patients with right heart failure is (positive sign of hepatic jugular vein reflux).
12. For patients with heart failure who take diuretics (furosemide) for a long time, the most important adverse reaction that nurses should pay attention to is (hypokalemia).
13, clinical treatment of heart failure, the main purpose of digitalis application (enhancing myocardial contractility).
14. In the process of using digitalis to treat patients with heart failure, nurses should ask and check the doctor's advice (intravenous drip of calcium gluconate solution).
15. Patients with heart failure treated with digoxin complained of obvious loss of appetite and blurred vision. The nurse measured the heart rate of 50 beats per minute and arrhythmia. The most likely cause is digitalis poisoning.
16. When potassium is supplemented intravenously, the maximum amount of 10% potassium chloride that can be added to 200ml normal saline is (6 ml).
17. Digitalis is the drug that requires routine measurement of pulse or heart rate before taking it.
18, and the drug that needs to be protected from light is (sodium nitroprusside)
19. During ECG examination, the electrode of unipolar chest lead V 1 should be placed (in the fourth intercostal space of the right sternum).
20. Bradycardia means that in a quiet state, the adult pulse rate is lower than (60 times) per minute.
2 1-39 knowledge points
2 1. In order to evaluate the antihypertensive effect of oral antihypertensive drugs, patients measured and recorded their blood pressure. The best time to measure blood pressure is (2 hours after taking antihypertensive drugs)
22. The arrhythmia that can be relieved by relieving tension is (atrial premature beat).
23, the most critical type of arrhythmia (ventricular fibrillation)
24, install permanent pacemaker 10 days after the correct discharge guidance is (learn to self-test the pulse every day).
25, belong to cyanotic congenital heart disease is (tetralogy of Fallot).
26, tetralogy of Fallot children should take the position of hypoxia attack is (knee chest position).
27. When children with tetralogy of Fallot suffer from hypoxic attack, the purpose of treatment with procaine is to (slow down the heart rate).
28. When children with congenital heart disease are discharged from hospital, it is wrong to give health education to their parents (take an active part in various sports).
29. When nursing children with tetralogy of Fallot, the main purpose of giving enough water is to prevent cerebral thrombosis.
30. According to the definition and classification of blood pressure level, the blood pressure of 130/88mmHg belongs to (normal high value).
Grade 3 1 and grade 3 hypertension refers to the range of blood pressure (systolic pressure ≥ 180mmHg, diastolic pressure ≥ 1 10mmHg).
32. Patient, male, 55 years old. Recently, the blood pressure fluctuated between (160 ~170)/(90 ~ 95) mmhg, and it was diagnosed as hypertension, belonging to grade 2 hypertension.
33, elderly patients with hypertension, in order to reduce the patient's weight, the appropriate exercise is (walking).
34, through diuretic effect to achieve antihypertensive effect of drugs is (hydrochlorothiazide)
35. The main mechanism of diuretics in lowering blood pressure is (reducing blood volume).
36. After using furosemide for diuresis, the patient developed symptoms of fatigue, abdominal distension and decreased bowel sounds. The patient may have (hypokalemia)
37. The most common side effect of captopril is (irritating dry cough).
38. In the nursing of antihypertensive drugs, patients should be guided to slowly change their postures, with the aim of (avoiding postural hypotension).
39. For hypertensive patients who like to eat pickled foods such as pickles, the most important dietary care guidance is (low sodium diet).