1、美国护士资格认证(CGFNS)-4 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.In teaching a female client who is HIV-positive about pregnancy, the nurse would know more teaching is necessary when the client says,A. “The baby can get the virus from my placenta. “B. “Im planning on starting on birth contro
2、l pills. “C. “Not everyone who has the virus gives birth to a baby who has the virus. “D. “Ill need to have a C-section if I become pregnant and have a baby. /（分数：1.00）A.B.C.D.2.After a client receives an IM injection, he complains of burning pain in the injection site. Which nursing action would be
3、 the best to take at this time?A. Apply a cold compress to decrease swelling.B. Apply a warm compress to dilate the blood vessels.C. Massage the area to promote absorption of the drug.D. Instruct the client to tighten his gluteal muscles to promote better absorption.（分数：1.00）A.B.C.D.3.A client with
4、a pneumothorax receives a chest tube attached to a Pleur-evac. The nurse notices that the fluid of the second chamber of the Pleur-evac isnt bubbling. Which nursing assumption would be most invalid?A. The tubing from the client to the chamber is blocked.B. There is a leak somewhere in the tubing sys
5、tem.C. The clients affected lung has reexpanded.D. The tubing needs to be cleared of fluid.（分数：1.00）A.B.C.D.4.The nurse assesses a client with urticaria. The nurse understands that urticaria is another name forA. hives.B. a toxin.C. a tubercle.D. a virus.（分数：1.00）A.B.C.D.5.A client reveals to the nu
6、rse that hes sexually impotent. Which statement best expresses what the nurse should understand her client to mean?A. Hes disinterested in sexual intimacy.B. Hes unable to attain or retain an erection.C. His ejaculate is void of sperm.D. His semen isnt potent enough to impregnate.（分数：1.00）A.B.C.D.6.
7、The nurse is teaching the mother of an infant with tetralogy of Fallot. The mother asks what to do when her infant becomes very blue and has trouble breathing after crying. The nurse should tell the mother,A. “Leave the infant alone until the crying stops. “B. “Put the infant in the knee-chest posit
8、ion. “C. “Offer the infant a bottle of formula. “D. “Take the infant for a ride in the car. /（分数：1.00）A.B.C.D.7.Two middle-aged sisters have been diagnosed with Huntingtons disease. The children of these clients want to know what their chances are of developing this genetic disorder. The nurses best
9、 response would be.A. “Only women become symptomatic. “B. “This disorder is an autosomal dominant disorder, so each child has a 50% chance of inheriting it. “C. “This disorder is an autosomal recessive disorder, so each child has a 25% chance of inheriting it. “D. “Women are symptomatic and men are
10、carriers of this disorder. /（分数：1.00）A.B.C.D.8.Because antianxiety agents such as chlordiazepoxide (Librium) can potentiate the effects of other drugs, the nurse should incorporate which of the following instructions in her teaching plan?A. Avoid mixing antianxiety agents with alcohol or other centr
11、al nervous system (CNS) depressants.B. Avoid taking antianxiety agents at bedtime.C. Avoid taking antianxiety agents on an empty stomach.D. Avoid consuming aged cheese when taking antianxiety agents.（分数：1.00）A.B.C.D.9.A 26-year-old male is admitted to an inpatient psychiatric hospital after having b
12、een picked up by the local police while walking around the neighborhood at night without shoes in the snow. He appears confused and disoriented. Which of the following is the most immediate nursing action?A. Assess and stabilize the clients medical needs.B. Assess and stabilize the clients psycholog
13、ical needs.C. Attempt to locate the nearest family member to get an accurate history.D. Arrange a transfer to the nearest medical facility.（分数：1.00）A.B.C.D.10.Before administering a tube feeding to a toddler, which of the following methods should the nurse use to check the placement of a nasogastric
14、 (NG) tube?A. Abdominal X-rays.B. Injection of a small amount of air while listening with a stethoscope over the abdominal area.C. A check of the pH of fluid aspirated from the tube.D. Visualization of the measurement mark on the tube made at the time of insertion.（分数：1.00）A.B.C.D.11.The nurse carin
15、g for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, its an expected finding of physiologic jaundice and is caused by which of the following?A. Poor clotting mechanism.B. High hemoglobin (Hb) levels between 14 and 20 g/dL per 100 mL of blood.C. Persisten
16、t fetal circulation.D. Large, immature liver.（分数：1.00）A.B.C.D.12.When caring for children who are sick, who have sustained traumas, or who are suffering from nutritional inadequacies, the nurse should know the correct hemoglobin (Hb) valuesfor children. Which of the following ranges would be inaccur
17、ate?A. Neonates. 10.6 to 16.5.B. 3 months. 10.6 to 16.5.C. 3 years. 9.4 to 15.5.D. 10 years. 10.7 to 15.5.（分数：1.00）A.B.C.D.13.During a clients chemotherapy regimen for breast cancer, which is important for the nurse to include in her plan of care?A. Instruct the client to consume plenty of raw fruit
18、s and vegetables.B. Take rectal temperatures for greater accuracy.C. Tell the client to avoid crowds and infected individuals.D. Ask friends and relatives not to visit during the course of chemotherapy.（分数：1.00）A.B.C.D.14.After taking glipizide (Glucotrol) for 9 months, a client experiences secondar
19、y failure. Which of the following would the nurse expect the physician to do?A. Initiate insulin therapy.B. Switch the client to a different oral antidiabetic agent.C. Prescribe an additional oral antidiabetic agent.D. Restrict carbohydrate intake to less than 30% of the total caloric intake.（分数：1.0
20、0）A.B.C.D.15.The nurse is caring for a 40-year-old woman who is a black Muslim. Which of the following choices is a concept on which black Muslims focus?A. Celibacy.B. Prophecy.C. Reincarnation.D. Self-esteem.（分数：1.00）A.B.C.D.16.When a client being seen in a fertility clinic doesnt respond to the cl
21、omiphene citrate, the physician prescribes IM menotropins (Pergonal). This drug increases her risk of producing multiple follicles that could mature to ovulation. To reduce the high risk of multifetal pregnancy and its possible adverse effects the nurse should monitorA. ultrasound study results and
22、serum estradiol levels.B. ultrasound study results and serum progesterone levels.C. results of tests to detect luteinizing hormone (LH) in urine.D. serum levels of human chorionic gonadotropin (HCG).（分数：1.00）A.B.C.D.17.A client in acute renal failure is admitted to the nephrology unit. The period of
23、 oliguria in these clients usually lasts about t0 days. Which of the following assessments of kidney function would the nurse make during the oliguric phase?A. No urine output; kidneys in a state of suppression.B. Urine output of 30 to 60 mL/hr.C. Urine output of less than 400 to 600 mL in 24 hours.
24、D. Urine output directly related to the amount of IV fluids infused.（分数：1.00）A.B.C.D.18.A client with thyroid cancer undergoes a thyroidectomy. After surgery, the client develops peripheral numbness and tingling and muscle twitching and spasms. The nurse should expect to administerA. thyroid supplem
25、ents.B. antispasmodics.C. barbiturates.D. IV calcium.（分数：1.00）A.B.C.D.19.When caring for a client who is having her second baby, the nurse can anticipate the clients labor will be which of the following?A. Shorter than her first labor.B. About half as long as her first labor.C. About the same length
26、 of time as her first labor.D. A length of time that cant be determined based on her first labor.（分数：1.00）A.B.C.D.20.An 82-year-old female is transferred to the hospital from a long-term care facility because of severe diarrhea. She is weak and dehydrated. Which acid-base imbalance could the client
27、develop as a result of diarrhea?A. Respiratory acidosis.B. Metabolic acidosis.C. Carbonic acid deficit.D. Metabolic alkalosis.（分数：1.00）A.B.C.D.21.The nurse is assessing a postcraniotomy client and finds the urine output from a catheter is 1,500 mL for the 1st hour and the same for the 2nd hour. The
28、nurse should suspectA. Cushings syndrome.B. diabetes mellitus.C. adrenal crisis.D. diabetes insipidus.（分数：1.00）A.B.C.D.22.When teaching the parents of a toddler with a congenital heart defect, the nurse should explain all medical treatments and should emphasize which instruction about their child?A.
29、 Reduce the caloric intake to decrease cardiac demand.B. Relax discipline and limit setting to prevent crying.C. Avoid contact with small children to reduce overstimulation.D. Try to maintain the usual lifestyle to promote normal development.（分数：1.00）A.B.C.D.23.On a routine visit to the physician, a
30、 client with chronic arterial occlusive disease reports stopping smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, the nurse should recommend which additional measure?A. Taking daily walks.B. Engaging in anaerobi
31、c exercise.C. Reducing daily fat intake to less than 45% of total calories.D. Avoiding foods that increase levels of high-density lipoproteins (HDLs).（分数：1.00）A.B.C.D.24.The nurse is evaluating a client who is complaining of shortness of breath. The clients respiratory rate is 26 breaths per minute
32、so the nurse documents that he is tachypneic. The nurse understands that tachypnea meansA. frequent bowel sounds.B. heart rate greater than 100 beats/minuteC. hyperventilation.D. respiratory rate greater than 20 breaths/minute（分数：1.00）A.B.C.D.25.A preschool-age child with sickle cell anemia is admit
33、ted to the health care facility in vaso-occlusive crisis after developing a fever and joint pain. What is the nurses highest priority when caring for this child?A. Providing fluids.B. Maintaining protective isolation.C. Applying cool compresses to affected joints.D. Administering antipyretics, as pr
34、escribed.（分数：1.00）A.B.C.D.26.The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should firstA. establish unresponsiveness.B. call for help.C. open the airway.D. assess the client for a carotid pulse.（分数：1.00）A.B.C.D.27.A client who survived an airplane crash has a di
35、agnosis 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 memories of trauma to a sympathetic listener.B. Family support.C. Pres
36、cribed medications taken as ordered.D. Alcoholics Anonymous (AA) meetings.（分数：1.00）A.B.C.D.28.The nurse is teaching the mother of a neonate. The nurse should instruct the mother to introduce her infant to solid foods at what age?A. 2 months.B. 4 months.C. 6 months.D. 8 months.（分数：1.00）A.B.C.D.29.A c
37、lient with shock brought on by hemorrhage has a temperature of 97.6F (36.4), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mmHg. For this client the nurse should question which physician order?A. “Monitor urine output every hour. “B. “Infuse
38、 IV fluids at 83 mL/hr“C. “Administer oxygen by nasal cannula at 3 L/min“D. “Draw samples for hemoglobin and hematocrit every 6 hours. /（分数：1.00）A.B.C.D.30.A client asks the nurse what PSA is. The nurse should reply that it stands forA. prostate-specific antigen, used to screen for prostate cancer.B
39、. protein serum antigen, used to determine protein levels.C. pneumococcal strep antigen, a bacteria that causes pneumonia.D. papanicolaou-specific antigen, used to screen for cervical cancer.（分数：1.00）A.B.C.D.二、Part Two(总题数：23，分数：23.00)31.The nurse is caring for a client who has a tracheostomy tube a
40、nd is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, byA. suctioning the tracheostomy tube frequently.B. using a cuffed tracheostomy tube.C. using the minimal air leak technique with cuff pressure less than 25 cmH2O.D.
41、keeping the tracheostomy tube plugged.（分数：1.00）A.B.C.D.32.An otherwise healthy adolescent has meningitis and is receiving IV and oral fluids. The nurse should monitor this clients fluid intake because fluid overload may causeA. cerebral edema.B. dehydration.C. heart failure.D. hypovolemic shock.（分数：
42、1.00）A.B.C.D.33.Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the following?A. Muscle weakness.B. Tremors.C. Diaphoresis.D. Constipation.（分数：1.00）A.B.C.D.34.After cancer chemotherapy, a client develops nausea and vomiting. For this client, the nurse
43、should give the highest priority to which action in the plan of care?A. Serve small portions of bland food.B. Encourage rhythmic breathing exercise.C. Administer metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed.D. Withhold fluids for the first 4 to 6 hours after chemotherapy admini
44、stration.（分数：1.00）A.B.C.D.35.A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous fistula was created in his left arm for hemodialysis. When preparing the client for discharge, the nurse should reinforce which dietary instruction?A. “Be sure to eat meat at every meal.
45、 “B. “Monitor your fruit intake and eat plenty of bananas. “C. “Restrict your salt intake. “D. “Drink plenty of fluids. /（分数：1.00）A.B.C.D.36.The nurse is caring for a neonate 12 hours after birth. Which clinical manifestation would be the earliest indication that the neonate may have cystic fibrosis
46、?A. Steatorrhea.B. Meconium ileus.C. Decreased sodium levels.D. Rhinorrhea.（分数：1.00）A.B.C.D.37.For a client with a head injury whose neck has been stabilized, the preferred bed position isA. Trendelenburgs.B. 30-degree head elevation.C. flat.D. side-lying.（分数：1.00）A.B.C.D.38.A client diagnosed with
47、anxiety disorder is prescribed buspirone (BuSpar). Teaching instructions for newly prescribed buspirone should include which of the following?A. A warning that immediate sedation can occur with a resultant drop in pulse.B. A reminder of the need to schedule blood work in 1 week to check blood levels
48、 of the drug.C. A warning about the incidence of neuroleptic malignant syndrome (NMS).D. A warning about the drugs delayed therapeutic effect, which is from 14 to 30 days.（分数：1.00）A.B.C.D.39.The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with he
49、art failure areA. tracheal.B. fine crackles.C. coarse crackles.D. friction rubs.（分数：1.00）A.B.C.D.40.The nurse is teaching a client with a history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client toA. avoid focusing on his weight.B. increase his activity level.C. follow a regular diet.D. continue leading a high-stress lifestyle.（分数：1.00）A.B.C.D.41.During her first prenatal visit, a client expresses concern about gaining weight. Which of the following would be the nurses best action?A. Ask the client how she feels about
