1、美国护士资格认证(CGFNS)-14 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-manager has noticed a sharp increase in the mediation errors with IV antibiotics over the last month. She discusses the situation with each nurse involved. What other action should she take?A. Document it on their ev
2、aluation.B. Ask them to attend inservice training for administration of IV medications.C. Report them to the supervisor.D. Report the incidents to the hospital attorney.(分数:1.00)A.B.C.D.2.A 72-year-old client seeks help for chronic constipation. This is a common problem for elderly clients due to se
3、veral factors related to aging. Which of the following is one such factor?A. Increased intestinal motility.B. Decreased abdominal strength.C. Increased intestinal bacteria.D. Decreased production of hydrochloric acid.(分数:1.00)A.B.C.D.3.The nurse is performing a painless, noninvasive procedure to mea
4、sure arterial oxygen saturation (SaO2). What procedure is it?A. Incentive spirometry.B. Arterial blood gas (ABG) measurement.C. Peak flow measurement.D. Pulse oximetry.(分数:1.00)A.B.C.D.4.The nurse is caring for a client whos hypoglycemic. This client will have a blood glucose levelA. below 70 mg/dL.
5、B. between 70 and 120 mg/dL.C. between 120 and 180 mg/dL.D. above 180 mg/dL.(分数:1.00)A.B.C.D.5.A client with hepatitis C develops liver failure and GI hemorrhage. The blood products that would most likely bring about hemostasis in the client areA. whole blood and albumin.B. platelets and packed red
6、blood cells.C. fresh frozen plasma and whole blood.D. cryoprecipitate and fresh frozen plasma.(分数:1.00)A.B.C.D.6.The nurse is interviewing the mother of a 7-year-old child. Which of the following symptoms reported by the mother would most lead the nurse to suspect that the child has type 1 diabetes?
7、A. Recent bed wetting.B. Poor appetite.C. Weight gain.D. Boundless energy.(分数:1.00)A.B.C.D.7.A client has just finished his glucose tolerance test. How many hours should it take for his blood glucose level to return to normal?A. 2 hours.B. 3 hours.C. 5 hours.D. 6 hours.(分数:1.00)A.B.C.D.8.The nurse i
8、s caring for a client infected with methicillin-resistant Staphylococcus aureus (MRSA). Whats the major infection control measure to reduce MRSA and other nosocomial pathogens in a health care setting?A. Using antibacterial soap when bathing clients with MRS.B. Conducting culture surveys periodicall
9、y.C. Ensuring that personnel wash their hands before and after contact with every client.D. Using specific housekeeping practices for environmental cleaning.(分数:1.00)A.B.C.D.9.The nurse is taking the health history of an 85-year-old client. Which information will be most useful to the nurse for plan
10、ning care?A. General health for the last 10 years.B. Current health promotion activities.C. Family history of diseases.D. Marital status.(分数:1.00)A.B.C.D.10.The nurse is teaching a client who receives nitrates for the relief of chest pain. Which of the following instructions should the nurse emphasi
11、ze?A. Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses.B. Store the drug in a cool, well-lit place.C. Lie down or sit in a chair for 5 to 10 minutes after taking the drug.D. Restrict alcohol intake to two drinks per day.(分数:1.00)A.B.C.D.11.The nurse is providing home care
12、 to a client with failing vision due to macular degeneration. The nurse is concerned about the clients safety. Which of the following activities would help to lessen the clients risk of falling?A. Arranging pieces of furniture close together so the client can use them for guidance and support.B. Enc
13、ouraging the client to wear a medical identification bracelet that describes the clients visual deficit.C. Installing a flashing light to indicate when the phone or doorbell is ringing.D. Installing handrails in hallways, in bathrooms, and on steps.(分数:1.00)A.B.C.D.12.The nurse is caring for four cl
14、ients on a step-down intensive care unit. The client at the highest risk for developing nosocomial pneumonia is the one whoA. has a respiratory infection.B. is intubated and on a ventilator.C. has pleural chest tubes.D. is receiving feedings through a jejunostomy tube.(分数:1.00)A.B.C.D.13.A client wi
15、th cholecystitis is receiving propantheline bromide. The client is given this medication because itA. reduces gastric solution production and hypermobility.B. slows emptying of the stomach and reduces chyme in the duodenum.C. inhibits contraction of the bile duct and gallbladder.D. decreases bile se
16、cretions.(分数:1.00)A.B.C.D.14.A client is receiving chemotherapy for cancer. The nurse reviews his laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?A. Activity intolerance.B. Impaired tissue integrity.C. Impaired oral muco
17、us membranes.D. Ineffective tissue perfusion (cerebral, cardiopulmonary, GI).(分数:1.00)A.B.C.D.15.The nurse is providing postoperative care for a client recovering from abdominal surgery. The client is receiving morphine through a client-controlled analgesia pump. Which finding would indicate that th
18、e client is obtaining adequate pain relief?A. Awakening several times during the night to redose.B. Respiratory rate of 10 breaths/minute.C. Pain rating of 2 or 3 on a scale of 0 to 10.D. Complaint of itching as an adverse effect of the analgesia.(分数:1.00)A.B.C.D.16.To assess a clients cranial nerve
19、 function, the nurse shouldA. assess hand grip.B. assess orientation to person, time, and place.C. assess arm drifting.D. assess gag reflex.(分数:1.00)A.B.C.D.17.The nurse suspects that a 68-year-old client has digoxin toxicity. The nurse should assess forA. hearing loss.B. vision changes.C. decreased
20、 urine output.D. gait instability.(分数:1.00)A.B.C.D.18.A client with hypotonic labor dysfunction is receiving oxytoein augmentation. Her contractions become more frequent and intense. Dilation progresses to 8 cm, but the fetal head remains at station +1. The nurse notes a soft bulge just above the sy
21、mphysis. Which of the following actions is best?A. Re-evaluate the fetal presentation.B. Change the clients position.C. Offer a narcotic analgesic.D. Help the client urinate.(分数:1.00)A.B.C.D.19.A 35-year-old client is undergoing a brain computed tomography (CT) scan because of continued migraine hea
22、daches. Hes placed in the CT scanner and suddenly begins to complain of palpitations, sweating, shortness of breath, and shaking. The client is most likely experiencingA. an allergic reaction.B. a myocardial infarction (MI).C. a panic attack.D. a hypoglycemic episode.(分数:1.00)A.B.C.D.20.A 6-year-old
23、 girl has been hospitalized with rheumatic fever for 4 weeks. Her symptoms have gradually subsided, and shes now ready for discharge. Which of the following plans for her health care is most important for her future well-being?A. Arrange for her to return to school as soon as possible to promote psy
24、chosocial development.B. Encourage her to engage in unrestricted physical activity to regain physical strength.C. Arrange for the administration of prophylactic antibiotics to prevent a recurrence of rheumatic fever.D. Maintain seizure precautions, as central nervous system involvement may persist f
25、or several months.(分数:1.00)A.B.C.D.21.Which of the following nutritional deficiencies may delay wound healing?A. Lack of thiamine.B. Lack of vitamin .C. Lack of folate.D. Lack of vitamin .(分数:1.00)A.B.C.D.22.In planning a presentation that advocates a decrease in the client-to-nurse ratio from 8:1 t
26、o 6:1, a nurse should emphasize its effect onA. institutional resources.B. standards of practice.C. client-care quality.D. nursing recruitment.(分数:1.00)A.B.C.D.23.A primigravida in labor for 13 hours clenches her fists, tightens her muscles, and screams during every contraction. Her reaction to labo
27、r seems exaggerated compared to the contraction pattern recording from the electronic fetal monitor (EFM). Whats the nurses best response?A. Explain to the client that the EFM shows mild contractions, so she should just relax and let the contractions work.B. Take over as her coach because her husban
28、d isnt helping her properly.C. Ignore her reactions, realizing that this is her first time in labor and her reactions will soon match the intensity of contractions shown on the EFM.D. Palpate her abdomen to determine the intensity of labor contractions as theyre taking place.(分数:1.00)A.B.C.D.24.The
29、nurse is providing postprocedure care for a client who underwent percutaneouslithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client toA. li
30、mit oral fluid intake for 1 to 2 weeks.B. report the presence of fine, sandlike particles through the nephrostomy tube.C. notify the physician about cloudy or foul-smelling urine.D. report bright pink urine within 24 hours after the procedure.(分数:1.00)A.B.C.D.25.A client has been prescribed 75 mg of
31、 amitriptyline (Elavil) at bedtime and 15 mg of phenelzine (Nardil) three times per day. Which nursing action takes priority?A. Teaching the client about the adverse effects.B. Calling the physician and questioning the order.C. Instituting dietary restrictions.D. Taking baseline vital signs.(分数:1.00
32、)A.B.C.D.26.A 26-year-old primigravida is in labor. Her cervix is 5 cm dilated and 75% effaced; the fetus is at 0 station. The client requests medication to relieve the discomfort of contractions, and the physician prescribes an epidural regional block. What position should the nurse help the client
33、 to assume when the epidural is administered?A. Lithotomy.B. Supine.C. Prone.D. Lateral.(分数:1.00)A.B.C.D.27.A client in her 7th month of pregnancy has been complaining of back pain and wants to know what can be done to relieve it. Which of the following responses by the nurse is most effective?A. “Y
34、ou need to lie down more during the day to get off your feet. “B. “Avoid lifting heavy loads, and try using the pelvic tilt exercise. “C. “Have others pick things up for you so you dont have to bend over so much. “D. “Your back pain will go away after the baby is born. /(分数:1.00)A.B.C.D.28.The nurse
35、 is teaching a psychiatric client about her prescribed drugs, chlorpromazine and benztropine. Why is benztropine administered?A. To reduce psychotic symptoms.B. To reduce extrapyramidal symptoms.C. To control nausea and vomiting.D. To relieve anxiety.(分数:1.00)A.B.C.D.29.The nurse is caring for a cli
36、ent with diabetes mellitus. When teaching the client about foot care, which instruction should the nurse provide?A. Examine feet once per week for redness, blisters, and abrasions.B. Apply lotion to dry feet, especially between the toes.C. Avoid hot-water bottles and heating pads.D. Dry feet vigorou
37、sly after each bath.(分数:1.00)A.B.C.D.30.The nurse is caring for a woman with phenylketonuria who wants to start a family. Which of the following guidelines should the nurse provide the woman?A. Follow a low-phenylalanine diet before trying to conceive.B. A low-phenylalanine diet is necessary only du
38、ring the first trimester.C. Begin a low-phenylalanine diet when pregnancy is confirmed.D. Dietary restrictions wont be necessary.(分数:1.00)A.B.C.D.二、Part Two(总题数:23,分数:23.00)31.The nurse should anticipate which psychological reactions during the second trimester of pregnancy?A. Self-centeredness and
39、concentration on the behavior and appearance of children.B. Extroversion and emotional lability.C. Ambivalence and uncertainty.D. Dismay over body image and readiness for the end of pregnancy.(分数:1.00)A.B.C.D.32.A 13-year-old visits the school nurse because hes experiencing back pain, fatigue, and d
40、yspnea. The nurse suspects that the child may have scoliosis. The nurse should firstA. send the child home to recover.B. inspect the child for uneven shoulder height or uneven hip height.C. arrange for the child to have spinal X-rays as soon as possible.D. ask the childs parent to take him to a phys
41、ician immediately.(分数:1.00)A.B.C.D.33.A 69-year-old client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?A. OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints.B. OA and RA are very simila
42、r. OA affects the smaller joints, and RA affects the larger, weight-bearing joints.C. OA affects joints on both sides of the body. RA is usually unilateral.D. OA is more common in women. RA is more common in men.(分数:1.00)A.B.C.D.34.The nurse is about to administer a medication to a client with whom
43、the nurse is unfamiliar. To verify the clients identity, the nurse shouldA. ask the client his name.B. check the name posted outside the clients room.C. ask a family member the identity of the client.D. check the clients identification bracelet.(分数:1.00)A.B.C.D.35.While monitoring a client for the d
44、evelopment of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters?A. Platelet count, prothrombin time (PT), and partial thromboplastin time (PTT).B. Platelet count, blood glucose levels, and white blood cell (WBC) count.C. Thrombin time, calcium lev
45、els, and potassium levels.D. Fibrinogen level, WBC count, and platelet count.(分数:1.00)A.B.C.D.36.A persons psychosocial needs during the dying process of a relative may includeA. flexible visitation, participation in client care, and rest breaks.B. flexible visitation, denial of imminent death, and
46、rest breaks.C. limited visitation, participation in client care, and rest breaks.D. short, frequent, limited periods of visitation; participation in client care; and rest breaks.(分数:1.00)A.B.C.D.37.While admitting a client with pneumonia, the nurse notes multiple bruises in various stages of healing
47、. The client has Alzheimers disease and a history of multiple fractures. Legally, the most important action for the nurse to take is toA. document findings thoroughly.B. question the client about the bruising.C. inform appropriate local authorities.D. tell the clients physician.(分数:1.00)A.B.C.D.38.A
48、 child is sent to the school nurse because, according to his teacher, hes constantly scratching his head. When the nurse assesses his hair and scalp, she finds evidence of lice. What did she probably see?A. Flaking of the scalp with pink, irritated skin exposed.B. Small white spots that adhere to th
49、e hair shaft, close to the scalp.C. Scaly, circumscribed patches on the scalp, with mild alopecia in these areas.D. Multiple tiny pustules on the scalp with no abnormal findings on the hair shafts.(分数:1.00)A.B.C.D.39.Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experienceA. heat intolerance and systolic hypertension.B. weight gain and heat intolerance.C. diastolic hypertension and widened pulse pressure.D. anorexia and hyperexcitability.(分数:1.00)A.B.C.D.40.The nurse is speaking to grieving