1、美国护士资格认证(CGFNS)-15 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 who agreed to become an organ donor is pronounced dead. What is the most important factor in selecting a transplant recipient?A. Blood relationship.B. Sex and size.C. Compatible blood and tissue types.D. Need.（分数：1.00
2、）A.B.C.D.2.The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. Shes in her 30s and has two young children. Although shes worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her copin
3、g?A. Tell the clients spouse or partner to be supportive while she recovers.B. Encourage the client to proceed with the next phase of treatment.C. Recommend that the client remain cheerful for the sake of her children.D. Refer the client to the American Cancer Societys Reach for Recovery program or
4、another support program.（分数：1.00）A.B.C.D.3.A 19-year-old primigravida is admitted to the labor and delivery unit in labor. Shes 2 cm dilated and 50% effaced, and the fetal head is at 0 station. Shes having moderately strong 40-second contractions every 5 minutes. She seems rather anxious and becomes
5、 very tense during each contraction. When the client asks for pain relief, what should the nurse do next?A. Determine the source of her anxiety and institute interventions to help her relax.B. Immediately check the physicians order and give her the analgesic ordered.C. Inform her that the neonates h
6、ead isnt down far enough just yet but that, as soon as it is, medication will be given.D. Tell her that her contractions are only moderately strong and that she should wait until later to take medication.（分数：1.00）A.B.C.D.4.The nurse is caring for a client admitted to the emergency department after a
7、 motor vehicle accident. Under the law, the nurse must obtain informed consent before treatment unlessA. the client is mentally ill.B. the client refuses to give informed consent.C. the client is in an emergency situation.D. the client asks the nurse to give substituted consent.（分数：1.00）A.B.C.D.5.Th
8、e nurse is caring for a client with otosclerosis scheduled to undergo a stapedectomy. The client asks the nurse when her hearing will improve. Which response by the nurse is most appropriate?A. Your hearing may not improve but youll no longer be bothered by tinnitus.B. Your hearing may be dramatical
9、ly improved right after surgery.C. You may notice improved hearing within 1 to 2 weeks.D. Your hearing may improve 3 to 6 weeks after surgery.（分数：1.00）A.B.C.D.6.A clients blood glucose level is 45 mg/dL. The nurse should be alert for which signs and symptoms?A. Coma, anxiety, confusion, headache, an
10、d cool, moist skin.B. Kussmauls respirations, dry skin, hypotension, and bradycardia.C. Polyuria, polydipsia, hypotension, and hypernatremia.D. Polyuria, polydipsia, polyphagia, and weight loss.（分数：1.00）A.B.C.D.7.When reporting to the surgeon that a chest tube is malfunctioning, the nurse is ordered
11、 to reposition the tube and obtain a chest radiograph. The nurse shouldA. inform the surgeon this isnt within her scope of practice.B. report the surgeon to the Ethics Committee.C. report the surgeon to the nursing supervisor.D. follow the order as requested by the surgeon.（分数：1.00）A.B.C.D.8.The nur
12、se is providing care to a client with catatonic type of schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse shouldA. ask the client which activity he would prefer to do first.B. negotiate a time when the client will perform activities.C. tell the client
13、specifically and concisely what needs to be done.D. prepare the client ahead of time for the activity.（分数：1.00）A.B.C.D.9.A client is admitted for a suspected eating disorder. Which of the following statements would indicate that the client may be suffering from anorexia nervosa?A. “Ive gained 3 poun
14、ds in the last month. “B. “I eat loads of spinach and yellow vegetables each day. “C. “Im a perfectionist, and I work hard to get As. “D. “I binge frequently in the morning and feel fat. /（分数：1.00）A.B.C.D.10.The nurse administers racemic epinephrine to a child. Ten minutes after administration, the
15、nurse should be alert forA. respiratory distress.B. profound tachycardia.C. signs of improved oxygenation.D. diminished cyanosis.（分数：1.00）A.B.C.D.11.A 4-month-old infant is brought to the pediatrician by his parents because theyre concerned about his frequent respiratory infections, poor feeding hab
16、its, frequent vomiting, and colic. The physician notes that the baby has failed to gain expected weight and recommends that the baby have a sweat test performed to detect possible cystic fibrosis. To prepare the parents for the test, the nurse should explain thatA. the baby will need to fast before
17、the test.B. a sample of blood will be necessary.C. a low-sodium diet is necessary for 24 hours before the test.D. a low-intensity, painless electrical current is applied to the skin.（分数：1.00）A.B.C.D.12.A 24-year-old client on the labor unit is being coached in the Lamaze method by her husband. On as
18、sessment, the nurse finds the client to be 5 cm dilated, 90% effaced, at +1 station with contractions coming every 2 to 3 minutes and lasting 35 to 40 seconds. The client has asked for pain relief. Whats the nurses best action?A. Check maternal blood pressure and pulse and fetal heart rate in respon
19、se to contractions.B. Realize that its too early to give pain medication, and encourage the husband to continue with the Lamaze coaching.C. Arrange for a sonogram to determine fetal position.D. Perform a vaginal examination to determine dilation, effacement, and station.（分数：1.00）A.B.C.D.13.Which fin
20、ding is considered normal in a neonate during the first few days after birth?A. Weight loss of 25%.B. Birth weight of 2,000 to 2,500 g.C. Weight loss then return to birth weight.D. Weight gain of 25%.（分数：1.00）A.B.C.D.14.The nurse is assigned to care for a postoperative client who has diabetes mellit
21、us. During the assessment interview, the client reports that hes impotent and says that hes concerned about its effect on his marriage. In planning this clients care, the most appropriate intervention would be toA. encourage the client to ask questions about personal sexuality.B. provide time for pr
22、ivacy.C. provide support for the spouse or significant other.D. suggest referral to a sex counselor or other appropriate professional.（分数：1.00）A.B.C.D.15.The nurse is assessing a client with possible Cushings syndrome. In a client with Cushings syndrome, the nurse would expect to findA. hypotension.
23、B. thick, coarse skin.C. deposits of adipose tissue in the trunk and dorsocervical area.D. weight gain in arms and legs.（分数：1.00）A.B.C.D.16.A client with coronary artery disease reports intermittent chest pain that occurs with exertion. The physician prescribes sublingual nitroglycerin. When teachin
24、g the client about nitroglycerin administration, the nurse should include which instruction?A. “Be careful after taking nitroglycerin because it may cause dizziness. “B. “Make sure you replace your nitroglycerin tablets every 6 months to ensure potency. “C. “A burning sensation after taking nitrogly
25、cerin indicates medication potency. “D. “When you experience chest pain, take one tablet every 30 minutes until the pain is relieved. /（分数：1.00）A.B.C.D.17.The nurse is caring for a （分数：1.00）A.B.C.D.18.The nurse is caring for a neonate with congenital clubfoot. After the final cast has been removed,
26、which member of the health care team will most likely help the neonate with leg and ankle exercises and provide his parents with a home exercise regimen?A. Occupational therapist.B. Physical therapist.C. Recreational therapist.D. Speech therapist.（分数：1.00）A.B.C.D.19.A client at term arrives at the l
27、abor room experiencing contractions every 4 minutes. After a brief assessment, shes admitted and an electronic fetal monitor is applied. Which of the following would alert the nurse to an increased potential for fetal distress?A. Weight gain of 30 lb (13.6 kg).B. Maternal age of 32 years.C. Blood pr
28、essure of 146/90 mmHg.D. Treatment for syphilis at 15 weeks gestation.（分数：1.00）A.B.C.D.20.Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down the left arm. The nurse notices that the client is restless
29、 and slightly diaphoretic, and measures a temperature of 99. 6F (37.6), a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90mmHg. Which nursing diagnosis takes highest priority?A. Risk for imbalanced body temperature.B. Decreas
30、ed cardiac output.C. Anxiety.D. Acute pain.（分数：1.00）A.B.C.D.21.A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse shouldA. tell him that shell leave for now but will return soon.B. ask him if its okay if she sits quietly with him.C. ask him why
31、he wants to be left alone.D. tell him that she wont let anything happen to him.（分数：1.00）A.B.C.D.22.A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely evidence of ineffective individual coping?A. Inability to make choices and decisions without advice.
32、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.C.D.23.When prioritizing a clients care plan based on Maslows hierarchy of needs, the nurses first priority would beA. allowing the fami
33、ly to see a newly admitted client.B. ambulating the client in the hallway.C. administering pain medication.D. placing wrist restraints on the client.（分数：1.00）A.B.C.D.24.When inserting a urinary catheter, the nurse can facilitate the insertion by asking the client toA. initiate a stream of urine.B. b
34、reathe deeply.C. turn to the side.D. hold the labia or shaft of penis.（分数：1.00）A.B.C.D.25.A 2-month-old neonate with diarrhea and vomiting has been receiving IV fluids for the past 24 hours. The specific gravity of the neonates urine is 1.012. What should the nurse do next?A. Check the neonates bloo
35、d pressure.B. Check the specific gravity again as soon as possible.C. Notify the physician.D. Continue the ordered IV flow rate.（分数：1.00）A.B.C.D.26.Which phrase is used to describe the volume of air inspired and expired with a normal breath?A. Total lung capacity.B. Forced vital capacity.C. Tidal vo
36、lume.D. Residual volume.（分数：1.00）A.B.C.D.27.A child with rheumatic fever complains of painful joints. What nonpharmacologic measures should the nurse use to reduce the childs pain?A. Performing gentle passive range-of-motion (ROM) exercises.B. Gently massaging the painful joints.C. Using a bed cradl
37、e to keep linens off the joints.D. Encouraging position changes in bed every 2 hours.（分数：1.00）A.B.C.D.28.A 56-year-old male has a blood pressure reading of 146/96mmHg. Upon hearing the reading, he exclaims, “My pressure has never been this high. Will I need to take medication to reduce it?“ Which of
38、 the following responses by the nurse would be best?A. “Yes. Hypertension is prevalent among males; its fortunate we caught this during your routine examination. “B. “Well need to reevaluate your blood pressure because your age places you at high risk for hypertension. “C. “A single elevated blood p
39、ressure doesnt confirm hypertension. Youll need to have your blood pressure reassessed several times before a diagnosis can be made. “D. “You have no need to worry. Your pressure is probably elevated because youre in the doctors office. /（分数：1.00）A.B.C.D.29.The nurse is developing a teaching plan fo
40、r a client diagnosed with diabetes insipidus. The nurse should include information about which hormone, commonly lacking in clients with diabetes insipidus?A. Antidiuretic hormone (ADH).B. Thyroid-stimulating hormone (TSH).C. Follicle-stimulating hormone (FSH).D. Luteinizing hormone (LH).（分数：1.00）A.
41、B.C.D.30.The nurse is providing care for a postoperative client who has undergone a small bowel resection. The nurse may use an epidural catheter for which of the following?A. Antibiotic therapy.B. Pain management.C. Blood transfusion.D. Anticoagulation.（分数：1.00）A.B.C.D.二、Part Two(总题数：23，分数：23.00)31
42、.The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which nursing diagnosis should receive the highest priority?A. Risk for self- or other-directed violence.B. Imbalanced nutrition.C. Ineffective coping.D. Impaired verbal communicatio
43、n.（分数：1.00）A.B.C.D.32.A pregnant client is taking folic acid. During prenatal teaching, which of the following foods would the nurse recommend as high in folic acid?A. Egg yolks.B. Fruit.C. Bread.D. Milk.（分数：1.00）A.B.C.D.33.The physician prescribes a monoamine oxidase (MAO) inhibitor for a client. W
44、hich of the following nursing diagnostic categories would be most appropriate to focus on during client teaching?A. Risk for injury.B. Disturbed thought processes.C. Deficient fluid volume.D. Disturbed sleep pattern.（分数：1.00）A.B.C.D.34.The nurse is working in a support group for clients with acquire
45、d immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?A. Avoiding the use of recreational drugs and alcohol.B. Refraining from telling anyone about the diagnosis.C. Following safer-sex practices.D. Telling potential sex partners about the diagnosis, as required by
46、 law.（分数：1.00）A.B.C.D.35.A nurse needs assistance transferring an elderly, confused client to bed. The nurse leaves the client to find someone to assist her with the transfer. While the nurse is gone, the client falls and hurts herself. The nurse is at fault because she hasntA. properly educated thi
47、s client about safety measures.B. restrained the client.C. documented that she left the client.D. arranged for continual care of the client.（分数：1.00）A.B.C.D.36.A 58-year-old client on a mental health unit has lost control, despite having been properly medicated, and is threatening to harm himself an
48、d others. He has been placed in four- point restraints. Which nursing measure should be taken next?A. Release one restraint every 15 minutes.B. Have a staff member stay with the client at all times.C. Leave the client alone to reduce his sensory stimulation and allow him to regain control.D. Restric
49、t fluids until the restraint period is over.（分数：1.00）A.B.C.D.37.A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?A. 9%.B. 18%.C. 27%.D. 36%.（分数：1.00）A.B.C.D.38.The mother of a hospitalized 3-year-old girl expresses concern because her daughter is wetting the bed. What should the nurse tell her?A. “Its common for a child to exhibit regressive behavior when anxious or stressed. “B. “Your child is probably angry about being hospitalized.
