1、美国护士资格认证(CGFNS)-3 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.Which of the following describes a preterm neonate?A. A neonate weighing less than 2,500 g (5 lb, 8 oz).B. A low-birth-weight neonate.C. A neonate born at less than 37 weeks gestation regardless of weight.D. A neonate diagnosed
2、 with intrauterine growth retardation.（分数：1.00）A.B.C.D.2.A child, age 5, with an IQ of 65 is admitted to the hospital for evaluation. When planning care, the nurse should keep in mind that this child isA. within the lower range of normal intelligence.B. mildly retarded but educable.C. moderately ret
3、arded but trainable.D. completely dependent on others for care.（分数：1.00）A.B.C.D.3.A client is admitted with atrial fibrillation. The physician noted a pulse deficit. The pulse deficit measures which of the following?A. The difference between apical and radial pulse rates.B. The difference between sy
4、stolic and diastolic blood pressures.C. The amount of blood ejected from the left ventricle per minute.D. The percentage of blood emptied from the ventricle during contraction.（分数：1.00）A.B.C.D.4.A client delivered a healthy full-term female neonate 2 hours ago by cesarean delivery. When assessing th
5、is client, which finding requires immediate nursing action?A. Tachycardia and hypotension.B. Gush of vaginal blood when the client stands up.C. Blood stain 2“ (5 cm) in diameter on the abdominal dressing.D. Complaints of abdominal pain.（分数：1.00）A.B.C.D.5.The nurse is caring for a client who required
6、 chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution, the nurse can anticipate that hell requireA. monitoring of arterial oxygen saturation (SaO2).B. arterial blood gas (ABG) studies.C. chest auscultation.D. a chest X-ray.（分数：1.00）A.B.C.D.6.During a morning assess
7、ment, the nurse percusses tympany. The nurse understands that tympany is a loud, high-pitched, moderately long sound with a drumlike, musical quality thats most commonly heard over theA. heart.B. liver.C. pancreas.D. stomach.（分数：1.00）A.B.C.D.7.A client has approached the nurse asking for advice on h
8、ow to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism isA. psychotherapy.B. total abstinence.C. Alcoholics Anonymous (AA).D. aversion therapy.（分数：1.00）A.B.C.D.8.A school-age child is admitted to the hospital with a diagnosis of acute
9、 lymphoblastic leukemia. The nurse formulates a nursing diagnosis of Risk for infection. Which of the following is the most effective way for the nurse to reduce the childs risk of infection?A. Implementing reverse isolation.B. Maintaining standard precautions.C. Requiring staff and visitors to wear
10、 masks.D. Practicing thorough hand washing.（分数：1.00）A.B.C.D.9.While assessing a 2-month-old childs airway, the nurse finds that the child isnt breathing. After two unsuccessful attempts to establish an airway, the nurse shouldA. attempt rescue breaths.B. attempt to reposition the airway a third time
11、.C. administer five back blows.D. attempt to ventilate with a handheld resuscitation bag.（分数：1.00）A.B.C.D.10.Which of the following activities should a 2-year-old child to be able to do?A. Build a tower of eight cubes.B. Point out a picture.C. Wash and dry his hands.D. Remove a garment.（分数：1.00）A.B.
12、C.D.11.A 20-year-old mother of a premature newborn smoked cigarettes during her pregnancy. Her son is a client in a neonatal intensive care unit and has a diagnosis of acute respiratory distress syndrome. Because the mother is Roman Catholic, which nursing intervention would be most appropriate for
13、the nurse to discuss with her?A. Baptism of the infant.B. Circumcision of the infant.C. Last rites for the infant.D. Sacraments of the sick for the mother.（分数：1.00）A.B.C.D.12.Which of the following would not be an indication of placental detachment?A. An abrupt lengthening of the cord.B. An increase
14、 in the number of contractions.C. Relaxation of the uterus.D. Increased vaginal bleeding.（分数：1.00）A.B.C.D.13.A client hospitalized with a pneumothorax has the following arterial blood gas (ABG) analysis: pH, 7.19; partial pressure of arterial carbon dioxide (PaCO2), 63 mmHg; and , 22 mEq/L. A chest
15、tube was inserted and oxygen administered at 4 L/min by nasal cannula. One hour after the initiation of treatment, ABG analysis reveals: pH, 7.28; PaCO2, 52 mmHg; and （分数：1.00）A.B.C.D.14.A client with a myocardial infarction (MI) develops pulmonary crackles and dyspnea. A chest X-ray shows evidence
16、of pulmonary edema. The specific type of MI the client had is most probablyA. anterior.B. posterior.C. lateral.D. inferior.（分数：1.00）A.B.C.D.15.The physician orders supplemental oxygen for a client with a respiratory problem. To provide the highest possible oxygen concentration, the nurse expects to
17、use which oxygen delivery device?A. Nasal cannula.B. Venturi mask.C. Partial rebreathing mask.D. Nonrebreathing mask.（分数：1.00）A.B.C.D.16.A client who has discovered a breast lump is tearful and expresses concern over her situation. The best way for the nurse to respond to her is byA. encouraging a d
18、iscussion of her problems and fears.B. asking her if she would like to talk to the chaplain.C. giving her reassurance.D. recommending a support group.（分数：1.00）A.B.C.D.17.The nurse is teaching a parent how to administer antibiotics at home to a child with acute otitis media. Which statement by the pa
19、rent indicates that teaching has been successful?A. “Ill give the antibiotics for the full 10-day course of treatment. “B. “Ill give the antibiotics until my childs ear pain is gone. “C. “Whenever my child is cranky or pulls on an ear, Ill give a dose of antibiotics. “D. “If the ear pain is gone, th
20、eres no need to see the physician for another ear examination. /（分数：1.00）A.B.C.D.18.A 68-year-old male client has been hospitalized repeatedly for chronic obstructive pulmonary disease (COPD). During this latest admission, he has refused to participate in his self-care. Every time the nurse approach
21、es him, the client states, “I just want to die. Im no good to anyone anymore. “ The nurse realizes that hes experiencingA. self-actualization.B. confabulation.C. reaction formation.D. grief.（分数：1.00）A.B.C.D.19.An 18-month-old child is brought to the emergency department with suspected croup. The chi
22、ld appears frightened and cries as the nurse approaches him. The nurse needs to assess the childs breath sounds. The best way to approach the child is toA. expose the childs chest quickly and auscultate breath sounds as quickly and efficiently as possible.B. ask the mother to wait briefly outside un
23、til the assessment is over.C. tell the child the nurse is going to listen to his chest with the stethoscope.D. allow the child to handle the stethoscope before listening to his lungs.（分数：1.00）A.B.C.D.20.A client has sustained a right tibial fracture and has just had a cast applied. Which instruction
24、 should the nurse provide in his cast care?A. Cover the cast with a blanket until the cast dries.B. Keep your right leg elevated above heart level.C. Use a knitting needle to scratch itches inside the cast.D. A foul smell from the cast is normal.（分数：1.00）A.B.C.D.21.A 32-year-old black man is admitte
25、d to the hospital in vaso-occlusive sickle cell crisis. He complains of chest pain, shortness of breath, severe myalgia, and arthralgia. Which of the following may be effective in relieving the clients joint pain?A. Applying ice packs to the joints.B. Performing active resistive range-of-motion exer
26、cises.C. Applying warm compresses to the joints.D. Applying transcutaneous electrical nerve stimulation (TENS).（分数：1.00）A.B.C.D.22.A client with pneumonia is receiving supplemental oxygen, 2 L/minute via nasal cannuta. The clients history includes chronic obstructive pulmonary disease (COPD) and cor
27、onary artery disease. Because of these findings, the nurse closely monitors the oxygen flow and the clients respiratory status. Which complication may arise if the client receives a high oxygen concentration?A. Apnea.B. Anginal pain.C. Respiratory alkalosis.D. Metabolic acidosis.（分数：1.00）A.B.C.D.23.
28、A client, now 37 weeks pregnant, calls the clinic because shes concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action?A. Make an appointment because the client needs to be evalua
29、ted.B. Explain that these are expected problems for the latter stages of pregnancy.C. Arrange for the client to be admitted to the birth center for delivery.D. Tell the client to go to the hospital; she may be experiencing signs of heart failure from a 45% to 50% increase in blood volume.（分数：1.00）A.
30、B.C.D.24.When planning care for a 7-year-old boy with Down syndrome, the nurse shouldA. plan interventions at the developmental level of a 7-year-old child because that is the childs age.B. plan interventions at the developmental level of a 5-year-old because the child will have developmental delays
31、.C. assess the childs current developmental level and plan care accordingly.D. direct all teaching to the parents because the child cant understand.（分数：1.00）A.B.C.D.25.A 70-year-old client with a diagnosis of left-sided cerebrovaseular accident is admitted to the facility. To prevent the development
32、 of disuse osteoporosis, which of the following objectives is most appropriate?A. Maintaining protein levels.B. Maintaining vitamin levels.C. Promoting weight-bearing exercises.D. Promoting range-of-motion (ROM) exercises.（分数：1.00）A.B.C.D.26.After assessing a newly admitted 5-year-old child, the nur
33、se makes the nursing diagnosis of Parental role conflict related to childs hospitalization. Which defining characteristic would most suggest this diagnosis?A. Supportive child-parent interaction (speaking, listening, touching, and eye-to-eye contact).B. Parents active participation in childs physica
34、l or emotional care.C. Parents failure to use available support systems or agencies to assist in coping.D. Evidence of adaptation to parental role changes.（分数：1.00）A.B.C.D.27.A client is scheduled to have a descending colostomy. Hes very anxious and has many questions concerning the surgical procedu
35、re, care of a stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team?A. Social worker.B. Registered dietitian.C. Occupational therapist.D. Enterostomal nurse therapist.（分数：1.00）A.B.C.D.28.What is the nurses most important r
36、ole in caring for a client with a mental health disorder?A. To offer advice.B. To know how to solve the clients problems.C. To establish trust and rapport.D. To set limits with the client.（分数：1.00）A.B.C.D.29.When caring for a client with a 3-cm stage 1 pressure ulcer on the coccyx, which of the foll
37、owing actions can the nurse institute independently?A. Using a povidone-iodine wash on the ulceration three times per day.B. Using a normal saline solution and applying a protective dressing as necessary.C. Applying an antibiotic cream to the area three times per day.D. Massaging the area with an as
38、tringent every 2 hours.（分数：1.00）A.B.C.D.30.The physician prescribes amoxicillin suspension 100 mg every 8 hours for a child who weighs 33 lb (15 kg). The drug is supplied in a bottle labeled 250 rag/teaspoon (1mL=50 mg). How many milliliters should the nurse administer?A. 2 mL.B. 2.5 mL.C. 5 mL.D. 7
39、.5 mL.（分数：1.00）A.B.C.D.二、Part Two(总题数：23，分数：23.00)31.When caring for a client who has recently delivered, the nurse assesses the client for urinary retention with overflow. Which of the following provides the most accurate picture of retention with overflow?A. Frequent trips to the bathroom with an
40、average output of 200 to 300 mL per void.B. Intense urge to urinate with an average output of 250 mL.C. A varying urge to urinate with an average output of 100 mL.D. Uterus displaced to the right with increased vaginal bleeding.（分数：1.00）A.B.C.D.32.A client reports substernal chest pain. Test results
41、 show electrocardiograph changes and an elevated cardiac troponin level. Which of the following should be the focus of nursing care?A. Improving myocardial oxygenation and reducing cardiac workload.B. Confirming a suspected diagnosis and preventing complications.C. Reducing anxiety and relieving pai
42、n.D. Eliminating stressors and providing a nondemanding environment.（分数：1.00）A.B.C.D.33.A term neonates mother is O-negative, and cord studies indicate that the neonate is A-positive. Which of the following would be least likely if the neonate developed neonate hemolytic disease?A. Lethargy or irrit
43、ability.B. Poor feeding patterns including vomiting.C. Weight loss greater than 10%.D. Signs of kernicterus.（分数：1.00）A.B.C.D.34.Otorrhea and rhinorrhea are most commonly seen with which type of skull fracture?A. Basilar.B. Temporal.C. Occipital.D. Parietal.（分数：1.00）A.B.C.D.35.Which of the following
44、is not a contributing factor to unstable blood sugars in the neonate?A. Prematurity.B. Respiratory distress.C. Postdated infant.D. Cesarean delivery.（分数：1.00）A.B.C.D.36.A 28-year-old nurse has complaints of itching and a rash of both hands. Contact dermatitis is initially suspected. The diagnosis is
45、 confirmed if the rash appearsA. erythematous with raised papules.B. dry and scaly with flaking skin.C. inflamed with weeping and crusting lesions.D. excoriated with multiple fissures.（分数：1.00）A.B.C.D.37.The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance tes
46、t results show a blood glucose level of 160 mg/dL. The nurse should anticipate that the client will need toA. start using insulin.B. start taking an oral antidiabetic drug.C. monitor her urine for glucose.D. be taught about diet.（分数：1.00）A.B.C.D.38.Which of the following describes the rationale for
47、administering vitamin K to every neonate?A. Neonates dont receive the clotting factor in utero.B. The neonate lacks intestinal flora to make the vitamin.C. It boosts the minimal level of vitamin K found in the neonate.D. The drug prevents the development of phenylketonuria (PKU).（分数：1.00）A.B.C.D.39.
48、Its important to assess the maturity of enzyme systems (kidney and liver) in which pediatric population before administering medications?A. Adolescents.B. Neonates.C. Premature infants.D. Toddlers.（分数：1.00）A.B.C.D.40.A 15-year-old female with a urinary tract infection is admitted to the facility. Sh
49、e tells the nurse she hopes shes pregnant. Which of the following would be the best response by the nurse?A. “Does your mother know about this?“B. “Tell me what pregnancy would mean to you. “C. “Congratulations. Does the babys father know?“D. “I hope you arent pregnant; youre too young. /（分数：1.00）A.B.C.D.41.A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?A. Inadequa
