A, soaking in peracetic acid and sterilizing; B, cleaning after autoclaving; C. concentrate dirty barrels; Expose to the sun and wash.
E. send it to an incinerator for incineration.
75. The patient, a 60-year-old male, was indwelling catheter due to urinary incontinence, and the drainage was smooth, but the urine was yellow and turbid. The doctor's advice is anti-infection treatment and pay attention to nursing.
A. hot compress the lower abdomen B. massage the lower abdomen C. acupuncture D. catheterization E. listening to the sound of running water
76. Child, 7 years old. Cough, expectoration for 5 days, the doctor's advice to give oxygen atomization inhalation treatment, the wrong operation is
A. The oxygen atomizing aspirator is closely connected with the oxygen device without air leakage. B put 1/2 cold distilled water into the oxygen humidification bottle.
C. adjust the oxygen flow 6? 8 l/min D. Hold the child's mouth with his mouth, let him close his lips and take a deep breath.
E after inhalation, remove the atomizer first, and then turn off the oxygen switch.
77. Patient, female, 35 years old. Diagnosis of herpes zoster, doctor's advice for intravenous injection of antiviral liquid, three times a day, the correct operation is
A. Select a thin and elastic blood vessel puncture B. Sterilize the injection site with 0.5% iodophor 1 time.
C, after seeing the blood return, fix the injection needle a little. D, the injection speed should be fast. E, don't press after pulling out the needle.
78. A 72-year-old male patient suffered from intermittent left heart failure due to coronary heart disease for 3 years. After quarreling with my family for a long time, I felt palpitation, shortness of breath, unable to lie down, coughing up pink foam sputum, and admitted to the emergency department. Physical examination: BP90/60 mmHg, R 28 times/minute, conscious, cyanosis in sitting position, wet snoring, wheezing in both lungs. Emergency nurses should give oxygen to patients in the following ways
A. continuous low flow oxygen inhalation B. intermittent low flow oxygen inhalation C. high flow oxygen inhalation D. low flow alcohol humidification oxygen inhalation E. high flow alcohol humidification oxygen inhalation
79. A male middle school student was diagnosed with acute icteric hepatitis A for nearly a week, feeling weak, poor appetite and pain in the liver area. The clinical manifestations of this patient should be excluded.
A. The urine color is dark yellow B. The stool color is dark brown C. The urine bilirubin test is positive D. The serum alanine aminotransferase (A 1T) is significantly increased.
E. HBsAg negative
80. A senior three student was hospitalized with pneumonia. He was depressed and anxious, unable to rest quietly and afraid of delaying his study. This behavior belongs to a. lack of role behavior.
B. Role behavior conflict C. Role behavior reinforcement D. Role behavior regression E. Role behavior change
(8 1 ~ 84 questions * * * are all dry goods)
Mr. Wang was in bed for 2 months because of cerebral thrombosis. He is incontinent and can't turn over by himself. Recently, the skin of the cauda sacrum is purple and red, and the compression does not subside.
8 1. According to this, we can judge which stage of pressure sore Mr. Zhang's skin performance belongs to.
A. Stagnant rosy stage B. Stagnant infiltration stage C. Inflammatory infiltration stage D. Superficial ulcer stage E. Deep ulcer stage
82. The main reasons for Mr. Zhang's pressure ulcer are
A. the local tissue is compressed for too long. B. Pathogenic bacteria invade skin tissue. The skin is stimulated by wet friction. D. malnutrition. E. skin damage.
83. Which of the following nursing measures is not appropriate?
A. Turn every 2 hours 1 time. Keep clothes and beds dry. C. Wipe the skin with warm water after wetting. D. Massage the sacrococcygeal region twice a day.
E. put an air cushion on the bed.
84. In order to prevent patients from other complications, nurses should focus on guiding their families to learn.
A. nasal feeding B. subcutaneous injection C. blood pressure measurement D. passive activity E. dressing change
(85 ~ 87 questions * * * are all dry goods)
Nurse Zhang needs to contact the superior doctor by telephone when she is involved in rescuing patients with hemorrhagic shock, and then she should pay attention to the telephone doctor's advice.
85. At this time, it is necessary
A. directly execute after hearing the doctor's advice. B. repeat it briefly. C. repeat it once and execute it after confirmation. D. blind execution.
E. carry out the doctor's advice you hear quickly.
86. After the rescue.
A. the nurse can record the rescue situation. B. The nurse records the rescue time and drugs used. C. clean up the rescue site.
D record the rescue process after placing the patient. E. Record the contents of doctor's orders in time, and urge doctors to fill in the doctor's orders and drugs in time.
87. Patients who fail to write medical records in time due to the rescue should be truthfully recorded after the rescue, and the time is after the rescue.
A. within 6 hours B. 1 day C. within half an hour D.3 days E. within a week.
(88? 90 questions * * * with questions)
A 74-year-old male patient with pneumonia suddenly developed dyspnea, cough, pink foam-like sputum and wet murmur in the auscultation lung during infusion.
88. This patient has the above situation because it happened.
A. Pulmonary embolism B. atelectasis C. Acute pulmonary edema D. Allergic reaction E. Fever reaction
89. When the above symptoms appear, the measures we should take immediately do not include
A. Stop infusion immediately and notify the doctor for first aid. B. give low flow oxygen inhalation.
C when conditions permit, the patient can sit up straight with his legs drooping. D. Give sedative, antiasthmatic, cardiotonic and diuretic drugs according to the doctor's advice.
E if necessary, the limbs should be ligated in turn to block the venous blood flow.
90. When the above happens, we can add ethanol to the oxygen inhalation humidification bottle, which has the following effects.
A. increase humidification effect B. reduce alveolar surface tension C. increase alveolar surface tension D. reduce alveolar foam surface tension.
E. prevent alveolar exudate from increasing.
(9 1? 94 questions * * * with questions)
The patient, a 28-year-old female, had to have a lateral perineal incision for delivery. Now the incision appeared red, swollen, hot and painful locally, and was given local irradiation by infrared lamp.
9 1. When using infrared lamp for local irradiation, the irradiation time should be controlled at.
A. 10 minutes B. 10~20 ~ 20 minutes C.20 ~ 30 minutes D.30 ~ 40 minutes E.40 ~ 50 minutes
92. In the process of irradiation, it was found that the local skin appeared purplish red. The measures to be taken are as follows
A. replace it with a low-power lamp holder. Increase the irradiation distance. C. switch to hot and humid applications. D. Stop using it immediately and apply vaseline locally. E. covering the local area with gauze.
93. After irradiation, ask the patient to rest for 15 minutes, and then leave the treatment room. with the purpose of
A. Observe the curative effect B. Prevent colds C. Prevent fainting D. Relieve pain E. Promote the limitation of inflammation
94. Further physical examination: temperature 38.8℃, pulse 108 beats/min, breathing 23 times/min. The best physical cooling method that can be used is
A. ice pack cold compress B. ice cap head cold compress C. alcohol rubbing bath D. warm water rubbing bath E. local cold wet compress
(95? 97 questions * * * and alternative answers)
A. Bilateral pupil contraction B. Early tentorial hiatus hernia C. Bilateral pupil dilation D. The pupil is oval and dilated.
E. the pupil's response to light disappears.
95. Patients in deep coma
96. Organophosphorus poisoning
97. Glaucoma
(98? 100 questions * * * and alternative answers)
A. head is low and feet are high, and head is tilted to one side. B. supine position without pillow. C. supine position, head leaning to one side. D. sitting posture. E. the diseased side.
98. Patients with bronchial asthma attack
99. Take it for patients with hemoptysis and asphyxia.
100. Pulmonary tuberculosis patients with massive hemoptysis
Reference answer
1, answer an analysis: avoiding the patient's inquiry about his illness can only aggravate the patient's anxiety.
2. answer c analysis: boiling, burning, soaking in disinfectant and soaking in 70% ethanol can kill tuberculosis bacteria. the simplest thing is to burn toilet paper with sputum.
3. answer c
4. Answer E: Nonverbal communication refers to communication without language, so facial expressions, gestures, body movements and body postures all belong to nonverbal communication, while verbal communication refers to communication with language, which can be written or oral. Health education materials are spread in written language, which belongs to language communication.
5. Answer C Analysis: The key to quickly correct tissue hypoperfusion and hypoxia caused by shock is to replenish blood volume.
6. Answer D Analysis: If the doctor's order is found to be obviously wrong, the nurse has the right to refuse to carry it out and question or defend it to the doctor, but she may not modify the doctor's order without authorization.
7.answer d
8. Answer an analysis: the head should be tilted to one side to prevent aspiration.
9. answer c
10. Answer an analysis: boiling 15 ~ 20 minutes can kill general bacteria, and boiling for more than 60 minutes can kill bacterial spores. 1 1. Answer A Analysis: The principle of drug storage is mainly investigated, in which yeast tablets are easily deliquescent oral drugs, so A is the correct answer.
12. answer d analysis: this question examines the pain response. A, B, C and E can all be caused by pain, but the changes of various indexes in option D are not caused by pain.
13. answer c analysis: the decrease of intracranial pressure makes the intracranial venous sinus and vein dilate or stretch, causing headache.
14. Answer A.
15. answer c analysis: long-term use of antibiotics is prone to flora imbalance, leading to fungal infection. In the process of oral care, it is necessary to observe whether there is fungal infection in oral mucosa.
16. answer d analysis: 3 degrees requires not only equipment and instruments, but also the help of others.
17. answer e analysis: this question examines the clinical manifestations of penicillin anaphylactic shock. Laryngeal edema and respiratory symptoms are the earliest symptoms, so e is the correct answer.
18. Answer E
19. Answer an analysis: When caring for dying patients, it is forbidden to dismantle the treatment pipeline without the consent of family members.
20. answer c analysis: bladder function training adopts intermittent clamping tube, which is opened every 3 ~ 4 hours to make the bladder fill and empty regularly and promote functional recovery.
2 1. answer d analysis: "disinfection management measures" stipulates that all medical devices, instruments and articles that enter sterile tissues or organs of human body must reach the sterilization level.
22. answer b analysis: anal temperature is the main temperature of children under 3 years old, and the insertion depth is 2 ~ 3 cm. Too deep anal surface is easy to rupture and cause damage, and too shallow measurement is inaccurate.
23. Analysis of answer C: The main purpose of using calcium gluconate is to investigate the treatment measures of streptomycin allergic reaction, so that streptomycin can combine with calcium ions and alleviate the symptoms of poisoning, so C is the correct answer.
24. Answer A Analysis: The Technical Specification for Cleaning and Disinfection of Endoscopes stipulates that the endoscope room should be divided into examination area, washing and disinfection area and cleaning area.
25. answer d analysis: the nursing goal statement consists of four parts: subject, predicate, code of conduct and conditional adverbial. The subject refers to the nursing object and can be omitted; Predicate refers to the observable behavior that the nursing object can complete; Behavior standard refers to the degree to which the nursing object completes this behavior, including time, distance, speed, etc. Conditional adverbial refers to the necessary conditions for nursing objects to complete this behavior. Option a is missing conditional adverbial; The subject of option b is incorrect; Option c lacks standards of conduct; Option e lacks the corresponding standard and conditional adverbial; Only d is complete.
26. answer d analysis: what is the correct statement to determine the diagnosis of lack of knowledge? Lack of knowledge: lack of knowledge? .
27. Answer C Analysis: During the clinical death period, the heartbeat and breathing stopped completely, various reflexes disappeared, and the pupils dilated, but various tissues and cells still had weak and short-lived metabolic activities.
28. answer c analysis: the functions of various systems are seriously damaged during the dying period, and the functions of the central nervous system above the brain stem are in a state of deep inhibition; Other items are clinical manifestations of death.
29. Answer D Analysis: The operating principle of aseptic technology stipulates that a sterile article can only be used by one person once to prevent cross-infection.
30. Answer E Analysis: Because of the specificity of TAT, there is no substitute drug, so desensitization injection is usually used for patients with positive test results. In a certain period of time, a small amount of antigen is used to consume the antibodies in the body many times, so that all of them are consumed. Finally, after injecting all the liquid medicine, the patient did not have allergic reaction. 3 1. Answer an analysis: In? Acute appendicitis? When an attack occurs, it is necessary to solve the patient's pain, fever and other problems first, which belongs to the physiological needs.
32. Answer E analysis: The time required for infusion = [total amount of liquid (ml) x drop number coefficient (drip/ml)]/[ number of drops per minute (drip/min) X6.0 (min)], and the calculation result is 6.25 hours, equivalent to 6 hours 15 minutes.
33. answer c analysis: it is not advisable to drink water immediately after taking drugs to soothe respiratory mucosa.
Answer D.
35. answer e analysis: when the eyelids cannot close on their own, they can be coated with chlortetracycline eye ointment or covered with vaseline gauze to prevent keratitis, conjunctivitis or ulcers caused by corneal dryness.
36. answer c analysis: venipuncture, when the operation is wrong, the needle is outside the blood vessel and the liquid is injected into the subcutaneous tissue, causing local swelling and pain; Local pallor, considering that the liquid medicine mistakenly enters the artery, the child screams because of high resistance and poor drip, and other operational errors will not cause local pallor.
37. Answer D analysis: In vitro tissue should be wrapped in sterile sheets as soon as possible, covered with plastic bags, and immediately frozen with ice cubes for 4 hours. C or so, to prevent ice water from infiltrating into plastic bags during refrigeration, and never immerse the severed limb in any liquid. 38. Answer B analysis: the external jugular vein is suitable: ① long-term infusion, and the peripheral vein is not suitable for puncture; ② Long-term intravenous drip of high concentration or irritant drugs, or intravenous hypernutrition therapy; ③ Critical patients with peripheral circulation failure are used to measure central venous pressure.
39. answer b analysis: the child has a high fever due to upper respiratory tract infection. At this time, the best nursing measure is physical cooling, such as cold compress on the head, warm water bath or cold saline enema.
40. answer c analysis: if constipation occurs, a large number of enemas are prohibited, and laxatives or low-pressure enemas can be used.
4 1. answer d analysis: this question examines the meaning of the abbreviation of administration time, ac stands for before meals, so d is the correct answer.
42. Answer E analysis: fecal occult blood test is positive when it is greater than 5ml, black stool when it is greater than 60ml, and circulatory symptoms when it is greater than 500ml.
43. Answer D Analysis: The main clinical feature of abdominal parenchymal organ rupture is internal bleeding. After bleeding, the blood does not coagulate due to the defibrasion of the abdominal cavity, so if the blood does not coagulate, it means that the substantive organ is broken.
44. answer c analysis: premature rupture of membranes during pregnancy should be lying with head down and feet high to prevent umbilical cord prolapse.
45. Answer C Analysis: Due to the anatomical position of the sigmoid colon, the patient should take the left lateral position during the enema operation.
46. answer c analysis: it is forbidden to take a bath with alcohol to avoid subcutaneous bleeding.
47. Answer an analysis: Aspirin has a strong stimulating effect on the gastrointestinal tract, and taking it with food can reduce the irritation to the gastrointestinal tract.
48. answer d analysis: the embryo calls before the eighth week of pregnancy (that is, 6 weeks after fertilization), and the fetus calls from the ninth week of pregnancy.
49. Answer D analysis: The period of ovarian functional maturity accompanied by sex hormone secretion and periodic ovulation is sexual maturity, which generally starts from 18 years old and lasts for about 30 years.
Answer an analysis: people who take short-acting oral contraceptives and want to get pregnant must get pregnant after stopping taking them for 6 months. Short-acting oral contraceptives have a temporary effect on the metabolism of the body, which can be recovered after stopping taking them.
5 1. answer d analysis: EEG in prodromal period is normal; Most of the somnolence period is a lethargic state; Shallow coma stage: can not induce flapping-wing tremor; During deep coma, all kinds of reflexes disappear.
52. Answer A: Magnesium milk is used for acidosis, 5% acetic acid is used for alkalosis, 3% hydrogen peroxide is used for vomiting, and sodium sulfate (barbital) is used for catharsis.
53. answer e analysis: e is the performance of type I respiratory failure, and others belong to the correct description of type II respiratory failure.
54. Answer an analysis: Patients with subarachnoid hemorrhage should stay in bed for 4 weeks with their heads slightly raised. Patients with bleeding should fast within 24 hours of onset, and if their condition is stable after 24 hours, they can be fed liquid food by nose. The patient placed an ice pack on his head to prevent further cerebral hemorrhage.
55. Answer E analysis: For people who eat a salt-free and low-sodium diet, they should abstain from salted products, as well as foods and drugs containing more sodium, such as alkaline foods such as fried dough sticks, dried noodles, sausages, soda and drugs containing sodium bicarbonate.
56. answer c analysis: intracranial hypertension caused by trauma is easy to form cerebellar notch hernia. In order to find cerebellar notch hernia in time, we should focus on observing the pupil.
57. Answer B analysis: People who are poisoned by oral organophosphorus pesticides repeatedly wash their stomachs with clear water until there is no garlic smell, and then induce diarrhea with sodium sulfate. People who are poisoned by skin and mucous membrane absorption should leave the scene immediately, take off the contaminated clothes, wash the contaminated skin repeatedly with soapy water, and do not scrub it with hot water or alcohol to prevent the blood vessels of the skin from dilating and promote the absorption of poison. Eye pollution should be washed continuously with 2% sodium bicarbonate solution or clean water.
58. answer b analysis: the manifestations of hyperthyroid non-invasive exophthalmos: exophthalmos, exophthalmos? 18 mm, blink decreases and cracks widen. The manifestations of infiltrative exophthalmos: the patient complained of photophobia, decreased vision and exophthalmos height (? 18 mm) causes corneal exposure and is easily stimulated by the outside world, causing congestion, edema, infection and even blindness.
59. answer b analysis: give high-flow oxygen 8 ~ 10 l/min.
60. Answer B analysis: After the hemolytic reaction, the nurse should immediately stop blood transfusion and notify the doctor, keep the remaining blood, collect the patient's blood sample and do blood group identification and cross-matching test again; Apply hot water bottles to both sides of waist and body; Closely observe vital signs and urine volume, and make records.
6 1. answer c analysis: zinc phosphide is easily soluble in oily substances, so it is not suitable to eat greasy food, so as not to promote the dissolution and absorption of phosphorus. 62. Analysis of answer B: Before the dialysate is injected into abdominal cavity, it should be heated to 37℃ and dried, because water bath heating is easy to be polluted.
63. Answer C analysis: The anal temperature will stop when it drops to 38℃.
64. Answer D. Analysis: Transfer is to transfer the emotion or behavior of one object to another more acceptable substitute object.
65. Answer C analysis: The onset of systemic sepsis is paroxysmal, and blood samples of blood culture and antibiotic sensitivity test should be preserved during shivering to improve the positive rate.
66. Answer C analysis: The patient needs gastrointestinal decompression after subtotal gastrectomy, but the intestinal function is normal at this time because
This is still acceptable for enteral nutrition, and nutrient solution can be injected into the intestine. Because the patient only receives nutritional support in a short period after operation, jejunostomy and nasointestinal tube placement are not needed.
67. answer d analysis: the light in the ward of tetanus patients should be dim.
Answer D.
Answer b
70. A: Outpatient nurses should always observe the patient's condition when arranging waiting and seeing a doctor. When encountering patients with high fever, severe pain, dyspnea, bleeding and shock, she should immediately arrange for medical treatment or send them to the emergency room for treatment. Therefore, according to Mr. Li's condition, the nurse should arrange for him to see a doctor in advance.
7 1. answer b
72. Answer B analysis: Patients with premature rupture of membranes should adopt a posture with head down and feet high to prevent umbilical cord prolapse.
Answer e
74. Answer E: The dressing of tetanus patients with special infection after dressing change should be contaminated, and incineration should be adopted. Therefore, it is the correct treatment method to send it to an incinerator for incineration.
75. Answer D
76. answer b analysis: when oxygen is atomized and inhaled, there is no water in the humidification bottle to prevent the liquid from entering the atomizer to dilute the liquid medicine.
77. answer c analysis: choose thick, straight and elastic blood vessel puncture when intravenous injection; Routine disinfection of injection site; After seeing the returned blood, inject a little needle and fix it safely; The injection speed should be slow; After the injection, press the local area until there is no bleeding.
79. Answer B Analysis: The clinical manifestations of acute icteric hepatitis are: pre-jaundice, jaundice and recovery. This child is in jaundice stage, with yellow urine and yellow scleral skin, which is about 1? It peaked in two weeks. Some patients may have obstructive jaundice such as light stool color and itchy skin.
80. Answer B analysis: Role-behavior conflict refers to the behavior disharmony caused by psychological conflict between patients and various roles before illness in the process of adapting to patients' roles.
8 1. answer C.
82. Answer A
83. answer d analysis: the compressed part should not be massaged during the inflammatory infiltration period to prevent rupture and infection.
84. Answer D analysis: Patients with limited mobility are given passive activities by their families to maintain joint mobility, prevent joint contracture and adhesion, and restore and improve joint function.
85. Answer C Analysis: When oral orders must be carried out under special circumstances such as emergency rescue of patients, the nurse must repeat the orders to the doctor and confirm them.
86. Answer E: After the doctor's order is executed, the time and content of the execution of the doctor's order and the patient's situation at that time should be recorded in time, and the doctor should make up the written doctor's order and medicine in time.
87. Answer A
Answer c
89. Answer B: Acute pulmonary edema should be inhaled with high flow of oxygen, and 30% alcohol should be added to the humidification bottle to increase the partial pressure of oxygen in alveoli, reduce the surface tension of foam in alveoli, increase oxygen diffusion and improve hypoxemia. Option C is to reduce venous reflux of lower limbs and reduce the burden on the heart, and option D is to relax peripheral blood vessels, accelerate fluid discharge, reduce blood reflux to the heart and reduce the burden on the heart.
90. Analysis of answer D: Putting 20% ~ 30% ethanol solution into the humidification bottle can reduce the tension on the foam surface in the alveoli, make the foam burst, expand the contact area between the gas and the alveolar wall, and make the gas easy to diffuse, thus improving the gas exchange function in the lungs. 9 1. answer C.
Answer d
Answer b
94. answer a analysis: the baking lamp is 30 ~ 50 cm away from the treatment site and the treatment time is 20 ~ 30 minutes. Adjust the distance and time of the lamp according to the patient's condition to prevent burning injury. It is advisable to have erythema on the skin. If it is purple, it indicates excessive. Stop using it immediately and apply vaseline locally. After irradiation, the patient should be told to rest 15 minutes before leaving the treatment room, so as to prevent the large temperature difference from causing a cold. Because of the high body temperature of the baking lamp, the patient used local cold therapy to lower his body temperature. Ice cap is beneficial to reduce brain temperature and prevent brain edema. The best way is cold compress with ice packs.
95. answer e analysis: when the pupil size does not change with light stimulation, it is said that the pupil's response to light disappears, which is common in patients with deep coma.
96. Answer A: Bilateral pupil contraction is common in organophosphorus pesticide poisoning, chlorpromazine poisoning, morphine poisoning and other drugs.
97. answer d analysis: the pupil is oval and dilated, which is common in glaucoma.
98. Answer D Analysis: When bronchial asthma attacks, patients should take an upright position to lower the diaphragm and relieve dyspnea.
99. Answer an analysis: Once the patient with hemoptysis has asphyxia, he should immediately lower his head and feet high, tilt his head to one side and pat his back to facilitate the discharge of blood clots.
100. answer e analysis: patients with pulmonary tuberculosis with massive hemoptysis should take the affected side and gently cough up blood. On the one hand, it is beneficial to expel hematocele from the respiratory tract, on the other hand, it can maintain the respiratory function of the healthy side, and reduce the incidence of tuberculosis diffusion caused by tuberculosis entering the healthy side with blood flow.