1、美国护士资格认证(CGFNS)-10 及答案解析(总分：53.00，做题时间：90 分钟)一、Part One(总题数：30，分数：30.00)1.A client reports a severe headache shortly after a lumbar puncture for a myelogram. What would be the nurses best response?A. Increase the clients fluid intake.B. Administer prescribed antihypertensives.C. Offer roll lenses to
2、 the client.D. Place cooling packs over the lumbar puncture site.（分数：1.00）A.B.C.D.2.As part of the respiratory assessment, the nurse observes the neonates nares for patency and mucus. Which of the following is the reason that the nurse employs this assessment?A. Neonates are obligate nose breathers.
3、B. Nasal patency is required for adequate feeding.C. Problems with nasal patency may cause flaring.D. A deviated septum will interfere with breathing.（分数：1.00）A.B.C.D.3.Which of the following statements represents a major principle of chronic pain management?A. A physiologic approach is most effecti
4、ve.B. A psychological approach is most effective.C. A pharmacologic approach is most effective.D. A multidisciplinary approach is most effective.（分数：1.00）A.B.C.D.4.The nurse instructs the client with diabetes mellitus that it is vital to recognize and treat hypoglycemia promptly based on which of th
5、e following knowledge?A. Hypoglycemia can cause brain damage.B. Hypoglycemia necessitates increased insulin dosage.C. The client may become dehydrated quickly.D. The client may become confused, increasing the risk of injury.（分数：1.00）A.B.C.D.5.A 22-year-old client is diagnosed with dependent personal
6、ity disorder. Which behavior is most likely to indicate her ineffective coping?A. Inability to make choices and decisions without advice.B. Showing interest only in solitary activities.C. Avoiding developing relationships.D. Recurrent self-destructive behavior with history of depression.（分数：1.00）A.B
7、.C.D.6.The skin lesions evident in herpes zoster are similar to those seen in which disease?A. Impetigo.B. Syphilis.C. Varicella.D. Rubella.（分数：1.00）A.B.C.D.7.During a shock state, the renin-angiotensin-aldosterone system exerts which effect on renal function?A. Decreased urine output, increased rea
8、bsorption of sodium and water.B. Decreased urine output, decreased reabsorption of sodium and water.C. Increased urine output, increased reabsorption of sodium and water.D. Increased urine output, decreased reabsorption of sodium and water.（分数：1.00）A.B.C.D.8.During the first 24 hours after a client
9、is diagnosed with addisonian crisis, which of the following should the nurse perform frequently?A. Weigh the client.B. Test urine for ketones.C. Assess vital signs.D. Administer oral hydrocortisone.（分数：1.00）A.B.C.D.9.Which of the following would the nurse do for a 4-year-old girl who has just had a
10、lumbar puncture?A. Administer narcotic analgesic for insertion site pain.B. Encourage the parents to hold the child.C. Ensure the child lies flat for at least 8 hours.D. Place a sandbag over the puncture site for 3 hours.（分数：1.00）A.B.C.D.10.A client is recovering from a gastric resection for peptic
11、ulcer disease. Which of the following outcomes indicates that the goal of adequate nutritional intake is being achieved 3 weeks following surgery?A. Increases food intake and tolerance gradually.B. Experiences occasional episodes of nausea and vomiting.C. Experiences a rapid weight gain within 1 wee
12、k.D. Drinks 2000 mL/day of water.（分数：1.00）A.B.C.D.11.A client in a psychiatric clinic unit tells the nurse, “I dont think I can face going home tomorrow. “ The nurse replies, “Do you want to talk more about it?“ The nurse is using which of the following techniques?A. Presenting reality.B. Making obs
13、ervations.C. Restating.D. Exploring.（分数：1.00）A.B.C.D.12.A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an IV infusion of oxytocin (Pitocin). Which of the following is LEAST likely to be included in her plan of care?A. Monitoring vital signs, i
14、ncluding assessment of fetal well-being, every 15 to 30 minutes.B. Allowing the client to ambulate as tolerated.C. Helping the client use breathing exercises to manage her contractions.D. Carefully titrating the oxytocin based on her pattern of labor.（分数：1.00）A.B.C.D.13.Which of the following would
15、be most appropriate for the nurse to include in the plan of care for a dying child to meet the childs emotional needs during the last days of life?A. Restrict visitors to the parents to avoid overtaxing the child.B. Answer the childs questions about illness and death honestly.C. Focus on the childs
16、physical needs to attempt to prevent sadness.D. Encourage the child to play quietly with a roommate to provide pleasure.（分数：1.00）A.B.C.D.14.The nurse recognizes that spinal shock is likely to persist for the first several weeks after the injury. Which of the following symptoms would be unexpected du
17、ring the period of spinal shock?A. Tachycardia.B. Rapid respirations.C. Hypertension.D. Dry, warm skin.（分数：1.00）A.B.C.D.15.The nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mmHg and he complains of dizziness. Whic
18、h medication would be used to treat his bradycardia?A. Atropine.B. Dobutamine (Dobutrex).C. Bretylium (Bretylol).D. Lidocaine (Xylocaine).（分数：1.00）A.B.C.D.16.The nurse is caring for a client who exhibits magical thinking. Which of the following best describes magical thinking?A. Strong positive and
19、negative feelings that cause conflict.B. Returning to an earlier developmental stage.C. Meaningless repetition of words.D. The belief that thoughts or wishes can control other people or events.（分数：1.00）A.B.C.D.17.The physician decides to artificially rupture the membranes. Following this procedure,
20、the nurse needs to check the fetal heart tones. Why should the nurse do so?A. To determine fetal well-being.B. To prepare for an imminent delivery.C. To assess for prolapsed cord.D. To assess fetal position.（分数：1.00）A.B.C.D.18.As part of the annual health screening, the nurse visits the eighth-grade
21、 physical education classes and asks each student to bend forward at the waist with the back parallel to the floor and the hands together at midline. For which of the following is the nurse assessing?A. Slipped epiphysis.B. Developmental dysplasia of hip.C. Idiopathic scoliosis.D. Physical dexterity
22、.（分数：1.00）A.B.C.D.19.Before bowel surgery, the infant is to receive oral neomycin for 3 days. The appropriate pediatric dosage of neomycin sulfate is 10. 3 mg/kg q 4 hours. The infant weighs 15 pounds, 6.4 ounces. Which of the following dosages most closely approximates a safe daily dose?A. 50 mg/da
23、y.B. 150 mg/day.C. 280 mg/day.D. 430 mg/day.（分数：1.00）A.B.C.D.20.A mother of a 4-month-old infant asks the nurse when she should wean from breast-feeding and begin using a cup. Which of the following would be the best indication of the infants readiness to be weaned?A. Taking solid foods well.B. Slee
24、ping through the night.C. Shortening the nursing time.D. Eating on a regular schedule.（分数：1.00）A.B.C.D.21.A client with hepatitis A expresses concern that his friends may also acquire hepatitis. Which of the following is most commonly used for prophylactic treatment of people exposed to hepatitis A?
25、A. Penicillin.B. Sulfadiazine (Microsulfon).C. Immune serum globulin.D. Interferon.（分数：1.00）A.B.C.D.22.Which event may trigger pain in the client with trigeminal neuralgia?A. Walking in the mall.B. Sitting in the sun.C. Eating lunch.D. Sleeping.（分数：1.00）A.B.C.D.23.Opiate withdrawal causes severe phy
26、sical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with which drug?A. Barbiturates.B. Amphetamines.C. Methadone.D. Benzodiazepines.（分数：1.00）A.B.C.D.24.The nurse preparing to give a child an intramuscular injection chooses to give the injecti
27、on into the gluteal muscle. The site is acceptable because which of the following reasons?A. The child has been walking for 1 year.B. The child has small deltoid muscles.C. The child is older than 2 years.D. The child weighs more than 25 pounds.（分数：1.00）A.B.C.D.25.The nurse is preparing to care for
28、a client diagnosed with catatonic schizophrenia. In anticipation of this clients arrival, what should the nurse do?A. Notify security.B. Prepare a magnesium sulfate drip.C. Place a specialty mattress overlay on the bed.D. Communicate the clients nothing-by-mouth status to the dietary department.（分数：
29、1.00）A.B.C.D.26.A client who survived an airplane crash has a diagnosis of posttraumatic stress disorder (PTSD). He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief for his symptoms?A. The opportunity to verbalize memori
30、es of trauma to a sympathetic listener.B. Family support.C. Prescribed medications taken as ordered.D. Alcoholics Anonymous (AA) meetings.（分数：1.00）A.B.C.D.27.Which of the following discharge instructions should the nurse give the parents of an infant with a temporary colostomy?A. Flush the stoma wit
31、h tap water at least once a day.B. Allow the diaper to absorb the colostomy drainage.C. Give the infant plenty of liquids to drink.D. Expect the stoma to become dusky red within 2 weeks.（分数：1.00）A.B.C.D.28.The nurse is caring for a client who undergoes a total right knee replacement. The nurse would
32、 anticipate which of the following activity orders for this client on the first postoperative day?A. Bed rest for 24 to 48 hours after surgery.B. Ambulate with walker twice a day.C. Up to chair with leg elevated.D. Dangle at bedside for 20 minutes.（分数：1.00）A.B.C.D.29.A client is admitted with a diag
33、nosis of delusions of grandeur. This diagnosis reflects the client has a belief that he isA. highly important or famous.B. being persecuted.C. connected to events unrelated to himself.D. responsible for the evil in the world.（分数：1.00）A.B.C.D.30.A client who has been admitted to the emergency room is
34、 restless and agitated, has dry mucous membranes, and is complaining of intense thirst. The nurse suspects which of the following electrolyte imbalances?A. Hypokalemia.B. Hypercalcemia.C. Hypomagnesemia.D. Hypernatremia.（分数：1.00）A.B.C.D.二、Part Two(总题数：23，分数：23.00)31.The nurse is irrigating a clients
35、 colostomy when the client complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse do first?A. Stop the flow of solution temporarily.B. Reposition the client on to her right side.C. Remove the irrigation tube.D. Massage the abdomen gently.（分数：1.
36、00）A.B.C.D.32.The nurse is preparing to administer a unit of blood to a client who is anemic. After its removal from the refrigerator, the blood should be administered withinA. 1 hour.B. 2 hours.C. 4 hours.D. 6 hours.（分数：1.00）A.B.C.D.33.Which of the following signs and symptoms would alert the nurse
37、 to possible internal bleeding in a client who has undergone pulmonary lobectomy?A. Increased blood pressure and decreased pulse and respiratory rates.B. Sanguineous drainage from the chest tube at a rate of 50 mL per hour during the past 3 hours.C. Restlessness and shortness of breath.D. Urine outp
38、ut of 180 mL during the past 3 hours.（分数：1.00）A.B.C.D.34.The nurse has been teaching the client strategies to prevent a recurrence of hemorrhoids. One strategy is maintaining a high-fiber diet. Which of the following breakfast menus is appropriate for the client?A. Danish pastry, prune juice, coffee
39、, and milk.B. Oatmeal, milk, grapefruit wedges, and bran muffin.C. Corn flakes, milk, white toast, and orange juice.D. Scrambled eggs, bacon, English muffin, and apple juice.（分数：1.00）A.B.C.D.35.The nurse is reviewing discharge instructions with a client after an uncomplicated delivery. Which of the
40、following symptoms is LEAST important in characterizing postpartum depression?A. Crying easily and feeling despondent.B. Loss of appetite and anxiety.C. Altered body image.D. Difficulty sleeping and poor concentration.（分数：1.00）A.B.C.D.36.The client underwent a bowel resection and was in the post-ane
41、sthesia recovery unit for 1 hour. She returns from the recovery room with an intravenous line, a nasogastrie tube, and a Foley catheter in place. She complains of pain and asks for medication. What should the nurse do?A. Administer the ordered narcotic.B. Establish the location and severity of pain.
42、C. Determine if she was medicated for pain in the post-anesthesia recovery unit.D. Reposition her and give her a back rub.（分数：1.00）A.B.C.D.37.A 10-year-old child with appendicitis is being prepared for surgery. Which of the following would be the nurses first action?A. Administer an enema.B. Insert
43、a nasogastric tube.C. Obtain vital signs.D. Administer antibiotics.（分数：1.00）A.B.C.D.38.A 19-year-old pregnant client tells the nurse shes concerned that she may not be able to take care of herself during her pregnancy. She states that prenatal care is expensive and her job doesnt provide insurance.
44、The nurse should recognize which of the following?A. The client may not take care of herself.B. The client may not be fit to take care of a child.C. The client needs to take up a second job.D. The client should be referred to community resources available for pregnant women.（分数：1.00）A.B.C.D.39.What
45、activity orders would be appropriate for a client with an internal radium implant for cervical cancer?A. Out of bed as tolerated within the room.B. Bed rest with bathroom privileges.C. Bed rest in position of comfort.D. Bed rest with the head of the bed flat.（分数：1.00）A.B.C.D.40.When administering an
46、 intramuscular injection to a neonate, which of the following muscles would the nurse consider as the best injection site?A. Deltoid.B. Dorsogluteal.C. Ventrogluteal.D. Vastus lateralis.（分数：1.00）A.B.C.D.41.A 30-year-old client with 7 months pregnancy reports severe leg cramps at night. Which nursing
47、 action would be most effective in helping her cope with these cramps?A. Suggesting that she walk for 1 hour twice per day.B. Advising her to take over-the-counter calcium supplements twice per day.C. Teaching her to dorsiflex her foot during the cramp.D. Instructing her to increase milk and cheese
48、intake to 8 to 10 servings per day.（分数：1.00）A.B.C.D.42.Which of the following would be LEAST appropriate to assess in a mother who is breast-feeding?A. The attachment of the neonate to the breast.B. The mothers comfort level with positioning the neonate.C. Audible swallowing.D. The neonates lips sma
49、cking.（分数：1.00）A.B.C.D.43.A 5-month-old infant is brought to the clinic by his parents because he “cries too much“ and “vomits a lot. “ The infants birth weight was 6 pounds, 10 ounces, and his current weight is 7 pounds, 4 ounces, falling below the 5th percentile on a standard growth chart. Which of the following data would the nurse identify as the priority?A. Frequency of regular checkups.B. Feeding pattern.C. Pattern of weight gain.D. Family dynamics.（分数：1.00）A.B.C.D.44.A client is recovering from coronary artery bypass grafting (CABG) surgery. The nurse knows that for sev
