2025年护士护理文书书写考核突破试卷及答案

2025年护士护理文书书写考核突破及答案2025年护士护理文书书写考核突破一、单项选择题（每题2分，共40分）1.下列属于客观资料的是（）A.患者感到头痛B.患者说心慌C.患者体温38.5℃D.患者自述腹痛2.护理记录单眉栏各项用（）填写A.铅笔B.钢笔C.蓝黑或碳素墨水笔D.圆珠笔3.首次护理记录单的书写要求不包括（）A.患者入院时间B.入院方式C.患者的心情D.主要病情4.体温单40-42℃之间的相应时间栏内纵行填写的内容是（）A.入院时间B.手术时间C.分娩时间D.以上都是5.护理文书书写应遵循的原则不包括（）A.客观B.真实C.准确D.随意6.医嘱处理后在医嘱本上标记的符号，临时医嘱应标记为（）A.√B.×C.△D.☆7.手术护理记录单中，器械、敷料清点数目应在（）清点A.手术开始前B.手术结束后C.手术开始前和手术结束后D.手术进行中8.下列关于护理文书保管期限的说法，正确的是（）A.体温单、医嘱单保管1年B.护理记录单保管3年C.门诊护理文书保管5年D.以上都对9.护理记录单中，护士签名应使用（）A.全名B.缩写名C.昵称D.英文名10.当患者病情发生变化时，护士应（）A.等待医生来处理再记录B.先记录病情变化，再通知医生C.立即通知医生，并及时记录病情变化及处理措施D.不用记录，等医生处理完再说11.下列哪项不属于护理文书中的表格类文书（）A.体温单B.医嘱单C.护理计划单D.手术护理记录单12.护理文书中，日期的填写格式正确的是（）A.2025/05/10B.2025-05-10C.2025.05.10D.以上都可以13.护理记录单中，对于病情稳定的患者，至少（）记录一次A.每天B.每2天C.每3天D.每周14.患者入院时，责任护士应在（）内完成首次护理记录A.2小时B.4小时C.6小时D.8小时15.医嘱执行单上的执行时间应精确到（）A.分钟B.小时C.天D.月16.护理文书书写过程中出现错字时，正确的处理方法是（）A.用涂改液涂改B.刮去错字后重写C.在错字上划双横线，就近书写正确的文字，并签全名D.直接在错字上写正确的字17.手术护理记录单中，手术体位应记录（）A.手术开始时的体位B.手术结束时的体位C.手术全过程的体位D.以上都不对18.护理文书中，对于过敏史的记录应包括（）A.过敏药物名称B.过敏反应表现C.发生时间D.以上都是19.患者出院后，护理文书应（）A.随意放置B.及时归档C.销毁D.交给患者带走20.下列关于护理文书法律意义的说法，错误的是（）A.是医疗纠纷处理的重要依据B.可以作为评价护理质量的依据C.与医疗事故的判定无关D.能反映护士的专业水平二、多项选择题（每题3分，共30分）1.护理文书的作用包括（）A.反映患者的病情变化B.为医疗、护理教学和科研提供资料C.是评价护理质量的重要依据D.在法律上可作为医疗纠纷的证据2.体温单的绘制内容包括（）A.体温B.脉搏C.呼吸D.血压3.护理记录单的书写内容包括（）A.患者的病情观察情况B.护理措施及执行情况C.患者的心理状态D.护理效果评价4.医嘱的种类包括（）A.长期医嘱B.临时医嘱C.备用医嘱D.口头医嘱5.手术护理记录单应记录的内容有（）A.患者基本信息B.手术名称C.术中用药情况D.器械、敷料清点情况6.护理文书书写的基本要求有（）A.文字工整、字迹清晰B.表述准确、语句通顺C.标点正确D.不得随意涂改7.下列关于护理文书保管的说法，正确的有（）A.应妥善保管，防止丢失B.可以随意借阅C.未经批准不得复印D.保管期满后按规定销毁8.护理记录单中，对于特殊检查、治疗的记录应包括（）A.检查、治疗的名称B.检查、治疗的时间C.检查、治疗的结果D.患者的反应9.护理文书中，对于患者的饮食情况记录应包括（）A.饮食种类B.饮食量C.食欲情况D.有无特殊饮食要求10.当护士发现医嘱有疑问时，应（）A.直接执行B.拒绝执行C.及时向医生提出疑问D.与其他护士商量后执行三、判断题（每题1分，共10分）1.护理文书可以使用简称，但必须是公认的、规范的简称。（）2.体温单上的大便次数，未解大便记为“0”。（）3.护理记录单可以由实习护士独立书写。（）4.医嘱执行后，应在医嘱本上及时标记。（）5.手术护理记录单中，器械、敷料清点数目不一致时，应立即重新清点，并记录清楚。（）6.护理文书书写只需要记录患者的病情，不需要记录患者的心理状态。（）7.患者出院后，护理文书可以由患者自行保管。（）8.护理文书中，日期和时间的填写可以根据个人习惯随意填写。（）9.当患者病情发生变化时，护士应先处理病情，再记录，最后通知医生。（）10.护理文书是护士工作的重要组成部分，能反映护士的专业素养和工作责任心。（）四、简答题（每题5分，共10分）1.简述护理文书书写的重要性。2.简述护理记录单的书写要求。五、案例分析题（10分）患者张某，男，65岁，因“突发胸痛2小时”入院。入院时患者神志清楚，面色苍白，大汗淋漓，主诉胸痛剧烈，呈压榨性，伴恶心、呕吐。体温36.8℃，脉搏110次/分，呼吸22次/分，血压90/60mmHg。心电图提示急性广泛前壁心肌梗死。医生下达医嘱：绝对卧床休息，持续吸氧2L/min，心电监护，建立静脉通道，给予硝酸甘油5mg加入5%葡萄糖注射液250ml中静脉滴注，密切观察病情变化。请根据上述案例，完成以下护理记录：首次护理记录：[记录时间][患者姓名][性别][年龄][入院时间][入院方式][诊断][主要病情][护理措施][护士签名]答案一、单项选择题1.C。客观资料是指通过观察、体检、仪器检查或实验室检查获得的资料，如体温、血压等。患者感到头痛、心慌、自述腹痛属于主观资料。2.C。护理记录单眉栏各项用蓝黑或碳素墨水笔填写，以保证记录的持久性和清晰性。3.C。首次护理记录单应记录患者入院时间、入院方式、主要病情等，患者的心情不属于首次护理记录单的必填内容。4.D。体温单40-42℃之间的相应时间栏内纵行填写入院、手术、分娩、转科、出院、死亡等时间。5.D。护理文书书写应遵循客观、真实、准确、及时、完整的原则，而不是随意书写。6.A。临时医嘱处理后在医嘱本上标记“√”。7.C。手术护理记录单中，器械、敷料清点数目应在手术开始前和手术结束后分别清点并记录。8.D。体温单、医嘱单保管1年，护理记录单保管3年，门诊护理文书保管5年。9.A。护理记录单中，护士签名应使用全名，以明确责任。10.C。当患者病情发生变化时，护士应立即通知医生，并及时记录病情变化及处理措施。11.C。护理计划单不属于表格类文书，体温单、医嘱单、手术护理记录单属于表格类文书。12.B。护理文书中，日期的填写格式一般为“年-月-日”，即2025-05-10。13.C。对于病情稳定的患者，护理记录至少每3天记录一次。14.B。患者入院时，责任护士应在4小时内完成首次护理记录。15.A。医嘱执行单上的执行时间应精确到分钟。16.C。护理文书书写过程中出现错字时，应在错字上划双横线，就近书写正确的文字，并签全名。17.C。手术护理记录单中，手术体位应记录手术全过程的体位。18.D。护理文书中，对于过敏史的记录应包括过敏药物名称、过敏反应表现、发生时间等。19.B。患者出院后，护理文书应及时归档，妥善保管。20.C。护理文书与医疗事故的判定密切相关，是医疗纠纷处理的重要依据，也可作为评价护理质量和反映护士专业水平的依据。二、多项选择题1.ABCD。护理文书能反映患者病情变化，为教学和科研提供资料，是评价护理质量的依据，在法律上可作为医疗纠纷的证据。2.ABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCABCA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