1、美国护士资格认证(CGFNS)-11 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.The nurse is teaching a client about using vaginal medications. The nurse should instruct the client toA. use a tampon after insertion to increase medication absorption.B. release and pull up on the applicator before removal.C
2、. never refrigerate suppositories.D. use only a water-soluble lubricant when inserting a suppository.(分数:1.00)A.B.C.D.2.A male client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of severe pain in the surgi
3、cal wound. Which action should the nurse take?A. Assume hes anxious about discharge, and administer pain medication.B. Assess the surgical site and affected extremity.C. Reassure the client that pain is a direct result of increased activity.D. Suspect a wound infection, and monitor the clients tempe
4、rature and vital signs.(分数:1.00)A.B.C.D.3.A 4-year-old girl is admitted to the hospital to rule out leukemia. Which of the following would be the best room assignment?A. With a 4-year-old girl who has rheumatoid arthritis.B. With a 5-year-old boy who is having a tonsillectomy.C. With a 4-year-old gi
5、rl who has leukemia.D. Alone in a private room.(分数:1.00)A.B.C.D.4.A client is to have a cesarean delivery because of continuous vaginal bleeding and an abnormal fetal heart rate tracing. Which of the following would be the best preoperative medication for this client?A. Meperidine (Demerol).B. Oxyto
6、cin (Pitocin).C. Promethazine (Phenergan).D. Glycopyrrolate (Robinul).(分数:1.00)A.B.C.D.5.The nurse is administering warfarin (Coumadin) to a client with deep vein thrombophlebitis. Which laboratory value indicates warfarin is at therapeutic levels?A. Partial thromboplastin time (PTT) to 2 times the
7、control.B. Prothrombin time (PT) (分数:1.00)A.B.C.D.6.An elderly client with Alzheimers disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential forA. hypoglycemia.B. fluid volume excess.C. aspiration
8、.D. constipation.(分数:1.00)A.B.C.D.7.The nurse teaches a mother how to provide adequate nutrition for her toddler, who has cerebral palsy. Which of the following observations indicates that teaching has been effective?A. The toddler stays neat while eating.B. The toddler finishes the meal within a sp
9、ecified period of time.C. The child lies down to rest after eating.D. The child eats finger foods by himself.(分数:1.00)A.B.C.D.8.The nurse is giving instructions to a client who is going home with a cast on his leg. Which point is most critical?A. Using crutches properly.B. Exercising joints above an
10、d below the cast, as ordered.C. Avoiding walking on a leg cast without the physicians permission.D. Reporting signs of impaired circulation.(分数:1.00)A.B.C.D.9.A 15-year-old primigravida gave birth 2 days ago. She tells the nurse that having her own little baby will be wonderful. Which nursing respon
11、se would best evaluate the accuracy of the clients expectations?A. “Tell me what your day will be like after you take your baby home. “B. “Will anyone be available to help you at home with the baby?“C. “Have you had any experience taking care of babies?“D. “What are you planning to do with your baby
12、 when you return to school?/(分数:1.00)A.B.C.D.10.The nurse provides fluid replacement for a client with burns on 35% of his body. It has been 12 hours since the burns occurred. His blood pressure is 85/60 mmHg. His pulse is 124 beats/minute. Urine output was 25 mL during the past hour. What orders sh
13、ould the nurse expect to receive from the physician?A. Maintain IV fluids at the present rate, and continue to reassess vital signs and urine output hourly.B. Increase the IV rate, and continue to reassess vital signs and urine output hourly.C. Decrease the IV rate, and continue to reassess vital si
14、gns and urine output hourly.D. Administer a vasoconstrictor, and reassess vital signs and urine output hourly.(分数:1.00)A.B.C.D.11.The nurse is teaching a new group of mental health aides. The nurse should teach the aides that setting limits is most important forA. a depressed client.B. a manic clien
15、t.C. a suicidal client.D. an anxious client.(分数:1.00)A.B.C.D.12.Which of the following assessments indicates fetal distress?A. Fetal scalp pH of 7.14.B. Fetal heart rate (FHR) of 144 beats/minute.C. Acceleration of FHR with contractions.D. Long-term variability.(分数:1.00)A.B.C.D.13.A female client ha
16、s just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually.B. The most common treatment is metronidazole (Flagyl),
17、 which should eradicate the problem within 7 to 10 days.C. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.D. The human papillomavirus (HPV), which causes condylomata aeuminata, cant be transmitted during oral sex.(分
18、数:1.00)A.B.C.D.14.Which procedure or practice is associated with surgical asepsis?A. Hand washing.B. Nasogastrie (NG) tube irrigation.C. Colostomy irrigation.D. IV catheter insertion.(分数:1.00)A.B.C.D.15.The nurse is caring for a client who is suicidal. When accompanying the client to the bathroom, t
19、he nurse shouldA. give him privacy in the bathroom.B. allow him to shave.C. open the window and allow him to get some fresh air.D. observe him.(分数:1.00)A.B.C.D.16.The nurse is caring for an elderly client who exhibits signs of dementia. The most common cause of dementia in an elderly client isA. del
20、irium.B. depression.C. excessive drug use.D. Alzheimers disease.(分数:1.00)A.B.C.D.17.The nurse is caring for a client who has hemoconcentration after fluid loss. Which IV fluids would be the most appropriate fluid replacement therapy for this client?A. Distilled water.B. Dextrose 5% in water (D5W) on
21、ly.C. DSW with 40 mEq of potassium chloride.D. Dextrose 10% in saline.(分数:1.00)A.B.C.D.18.The employer of a client on the psychiatric unit calls the nursing station inquiring about the clients progress. The nurse doesnt know if the client has given consent to allow the staff to give information out
22、to callers on the phone. Which of the following would be the nurses best response?A. “Im not permitted to discuss her progress. “B. “Ill give you the name and telephone number of her physician. “C. “Ill have her call you. “D. “I cant confirm whether your employee is a client here. /(分数:1.00)A.B.C.D.
23、19.Which client has the highest risk of ovarian cancer?A. 30-year-old woman taking oral contraceptive pills.B. 45-year-old woman who has never been pregnant.C. 40-year-old woman with three children.D. 36-year-old woman who had her first child at age 22.(分数:1.00)A.B.C.D.20.A 16-year-old student has b
24、een admitted to your psychiatric unit after fainting in physical education class. She has a diagnosis of anorexia nervosa, weighs 88 lb (40 kg), and is 54“ (1.6 m) tall. She has been weighing herself several times per day at home and has lost 30 lb (13.5 kg) in the past 3 months. Which nursing diagn
25、osis would be most appropriate for the client?A. Disturbed thought processes.B. Impaired adjustment.C. Imbalanced nutrition. Less than body requirements.D. Ineffective sexuality patterns.(分数:1.00)A.B.C.D.21.The nurse is assessing a 15-year-old female who is being admitted for treatment of anorexia n
26、ervosa. Which clinical manifestation is the nurse most likely to find?A. Tachycardia.B. Warm, flushed extremities.C. Parotid gland tenderness.D. Coarse hair growth.(分数:1.00)A.B.C.D.22.The nurse is caring for a client undergoing IV antibiotic therapy with gentamicin sulfate. Which of the following in
27、terventions is most important?A. Infuse the medication quickly to minimize its irritating effect on the walls of blood vessels.B. Obtain renal function tests, such as blood urea nitrogen (BUN) and creatinine levels, throughout the course of therapy.C. Assess for pulmonary and peripheral edema.D. Obt
28、ain an order for an antiemetic to counteract the common adverse effect of nausea.(分数:1.00)A.B.C.D.23.While evaluating the needs of a client during the second trimester, the nurse can anticipate which of the following?A. Feelings of disbelief and ambivalence.B. Feelings of clumsiness and “ugliness“.C
29、. Increasing introspection but a general sense of well-being.D. Anxiety about the labor and delivery experience.(分数:1.00)A.B.C.D.24.A family member is caring for a client diagnosed with Alzheimers disease. Which of the following is most likely to cause the caregiver depression and role strain?A. The
30、 caregiver had a close relationship with the client before diagnosis of the illness.B. The caregiver has no formal support, such as a visiting nurse or day care worker.C. The caregiver understands the full reality of the disease and its inevitable progression.D. The caregiver feels unable to control
31、 the client and unable to cope with caregiving.(分数:1.00)A.B.C.D.25.A 38-year-old client is hospitalized with obsessive-compulsive disorder. On admission, she becomes nervous and asks to go to the bathroom to brush her teeth. Her husband says that she brushes her teeth at least 25 times per day. The
32、nurse notes that the clients gums are inflamed and bleeding. Whats the best nursing intervention?A. Have her stop brushing her teeth until the gums heal.B. Allow her to continue her routine of daily brushing.C. Monitor her dental care and set limits on the amount of daily brushing.D. Brush her teeth
33、 for her.(分数:1.00)A.B.C.D.26.The nurse is caring for a client admitted to the hospital with a bowel obstruction. The nurse should wear sterile gloves whenA. inserting an indwelling urinary catheter.B. giving a back rub on intact skin.C. changing an oxygen system.D. inserting an IV catheter.(分数:1.00)
34、A.B.C.D.27.The nurse is preparing a treatment plan for a client taking oral corticosteroids to control severe chronic asthma. Which statement indicates that the client understands his treatment plan?A. “I should take corticosteroids on an empty stomach. “B. “I need to take corticosteroids to help bu
35、ild up my immune system. “C. “I should stop taking corticosteroids if I havent had an asthma attack for 1 week. “D. “Ill tell my other health care providers that Im taking a corticosteroid. /(分数:1.00)A.B.C.D.28.A client is taking spironolactone (Aldactone) to control her hypertension. Her serum pota
36、ssium level is 6 mEq/L. For this client, the nurses priority would be to assess herA. neuromuscular function.B. bowel sounds.C. respiratory rate.D. electrocardiogram (ECG) results.(分数:1.00)A.B.C.D.29.A nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for a
37、ssistance. In reassessing the infant after I minute of CPR, the nurse finds that he still isnt breathing and that he has no pulse. The nurse should thenA. resume CPR beginning with breaths.B. declare her efforts futile.C. resume CPR beginning with chest compressions.D. call for assistance.(分数:1.00)A
38、.B.C.D.30.A multigravida in her 34th week of gestation presents in the emergency department complaining of vaginal bleeding. Which of the following should be the nurses first action?A. Establish IV access.B. Assess fetal heart rate (FHR) and maternal blood pressure.C. Prepare the client for a cesare
39、an delivery.D. Assess maternal heart rate and respiratory rate.(分数:1.00)A.B.C.D.二、Part Two(总题数:23,分数:23.00)31.The nurse is planning care for a female client diagnosed with acute hepatitis A virus (HAV). Whats the primary mode of transmission for HAV?A. Fecal contamination and oral ingestion.B. Expos
40、ure to contaminated blood.C. Sexual activity with an infected partner.D. Sharing a contaminated needle or syringe.(分数:1.00)A.B.C.D.32.The nurse is delivering the clients 10 AM medications. The client is away from his room for a diagnostic study. Which action is the most appropriate for the nurse to
41、take?A. Leave the medications on the clients bedside table.B. Ask the clients roommate to keep the medications for the client until he returns.C. Lock the medications in the medicine preparation area until the client returns.D. Have the client skip that dose of medication.(分数:1.00)A.B.C.D.33.The nur
42、se is teaching a client who has been prescribed allopurinol for the treatment of gout. Which instruction would the nurse give to the client?A. Increase alcohol intake while taking the drug.B. Avoid foods that are rich in purine.C. Take aspirin for pain.D. Take the drug between meals to promote absor
43、ption.(分数:1.00)A.B.C.D.34.A 54-year-old female was found unconscious on the floor of her bathroom with self- inflicted wrist lacerations. An ambulance was called and the client was taken to the emergency department. When she was stable, the client was transferred to the inpatient psychiatric unit fo
44、r observation and treatment with antidepressants. Now that the client is feeling better, which nursing intervention is most appropriate?A. Observing for extrapyramidal symptoms.B. Beginning a therapeutic relationship.C. Canceling any no-suicide contracts.D. Continuing suicide precautions.(分数:1.00)A.
45、B.C.D.35.A nurse instructs a prenatal class about the importance of doing Kegel exercises frequently. Kegel exercises help toA. promote better breathing by strengthening the diaphragm muscle.B. maintain good perineal muscle tone by tightening the pubococcygeus muscle.C. minimize leg cramps by streng
46、thening the calf muscles.D. prepare the mother for pushing by strengthening the abdominal muscles.(分数:1.00)A.B.C.D.36.The nurse is developing a care plan for a client in her 34th week of gestation who is experiencing premature labor. What nonpharmacologic intervention should the plan include to halt
47、 premature labor?A. Encouraging ambulation.B. Serving a nutritious diet.C. Promoting adequate hydration.D. Performing nipple stimulation.(分数:1.00)A.B.C.D.37.The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get mammogramsA. year
48、ly after age 40.B. after the birth of the first child and every 2 years thereafter.C. after the first menstrual period and annually thereafter.D. every 3 years between ages 20 and 40 and annually thereafter.(分数:1.00)A.B.C.D.38.During a routine follow-up examination, the nurse updates the clients med
49、ication history. The client currently receives prednisone therapy. Concomitant use of an agent from which of the following classes could increase the risk of peptic ulcer disease?A. Antidiabetic agents, administered orally.B. Nonsteroidal anti-inflammatory drugs (NSAIDs).C. Beta-adrenergic blockers.D. Contraceptive agents, administered orally.(分数:1.00)A.B.C.D.39.The nurse is assessing a client diagnosed with appendicitis. Which of the following signs or symptoms should the nurse expect to find?A. Rigid abdomen, Levines sign, pain relief leaning forward.B. Rebound