1、美国护士资格认证(CGFNS)-8 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 with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550mL. What should the nurse do?A. Increase the frequency of
2、the catheterizations.B. Insert an indwelling urinary catheter.C. Place the client on fluid restrictions.D. Use a condom catheter instead of an invasive one.（分数：1.00）A.B.C.D.2.While inspecting the clients chest, the nurse notes that the chest wall contracts on inspiration and bulges on expiration. Th
3、e nurse suspects which of the following problem from this assessment?A. Hemothorax.B. Flail chest.C. Pneumothorax.D. Tension pneumothorax.（分数：1.00）A.B.C.D.3.A neonate receives an Apgar score at 1 and 5 minutes after birth. The 5-minute Apgar score is more predictive for which of the following?A. Res
4、idual neurologic damage.B. Residual respiratory depression.C. Congenital heart defects.D. Gestational age of the neonate.（分数：1.00）A.B.C.D.4.The nurse is caring for a client who complains of chronic pain. Given this complaint, why would the nurse simultaneously evaluate both general physical and psyc
5、hosocial problems?A. Depression is commonly characterized by pain disorders and somatic complaints.B. Combining evaluations will save time and allow for quicker delivery of health care.C. Most insurance plans wont cover evaluation of both as separate entities.D. The physician doesnt have the trainin
6、g to evaluate for psychosocial considerations.（分数：1.00）A.B.C.D.5.The nurse is caring for a client who exhibits signs of somatization. Which of the following statements is most relevant?A. Clients with somatization are cognitively impaired.B. Anxiety rarely coexists with somatization.C. Somatization
7、exists when medical evidence supports the symptoms.D. Clients with somatization often have lengthy medical records.（分数：1.00）A.B.C.D.6.The nurse is administering sublingual nitroglycerin (Nitrostat) to the client. Immediately afterward, the client may experience which of the following symptoms?A. Ner
8、vousness or paresthesia.B. Throbbing headache or dizziness.C. Drowsiness or blurred vision.D. Tinnitus or diplopia.（分数：1.00）A.B.C.D.7.A client with a history of panic attacks seeks to increase social interaction. Each time the client tries to go to the dayroom, she begins to perspire and becomes sho
9、rt of breath. Which action by the nurse will help ease the clients feelings of panic?A. Have other clients volunteer to accompany the client.B. Tell the client she has to overcome her fear.C. Allow the client to stay in her room.D. Walk with the client and stay with her while shes in the dayroom.（分数
10、：1.00）A.B.C.D.8.The client is taking lithium (Lithobid). Which instruct should the nurse give to the client?A. Drink at least six to eight glasses of water per day and to avoid caffeine.B. Limit the use of salt in his diet.C. Discontinue medicine when feeling better.D. Increase the amount of sodium
11、in his diet.（分数：1.00）A.B.C.D.9.The mother of a 9-month-old asks about adding new foods to his diet. The child is being breast-fed and takes formula and cereal when at the sitters. Which of the following would the nurse instruct the mother to do?A. Mix new foods with formula or breast milk.B. Mix new
12、 foods with more familiar foods.C. Offer new foods one at a time.D. Offer new foods after giving formula or breast milk.（分数：1.00）A.B.C.D.10.Which of the following drugs may be abused because of tolerance and physiologic dependence?A. Lithium (Lithobid) and divalproex (Depakote).B. Verapamil (Calan)
13、and chlorpromazine (Thorazine).C. Alprazolam (Xanax) and phenobarbital (Luminal).D. Clozapine (Clozaril) and amitriptyline (Elavil).（分数：1.00）A.B.C.D.11.The client with cirrhosis is put on a sodium-restricted diet and a diuretic. The nurse would expect to administer a potassium-sparing diuretic. Whic
14、h of the follow is a potassium-sparing diuretic?A. Furosemide (Lasix).B. Spironolactone (Aldactone).C. Hydrochlorothiazide (HydroDIURIL).D. Ethacrynic acid (Edecrin).（分数：1.00）A.B.C.D.12.While caring for a healthy neonate female, the nurse notices red stains on the diaper after the neonate voids. Whi
15、ch of the following should the nurse do?A. Call the physician to report the problem.B. Encourage the mother to feed the neonate to decrease dehydration.C. Check the neonates urine for hematuria.D. Do nothing because this is normal.（分数：1.00）A.B.C.D.13.A 16-year-old girl comes to the school nurse comp
16、laining of cramps, backache, and nausea with her periods. The nurse most likely would interpret these symptoms as which of the following?A. Pathologic.B. Physiologic.C. Psychogenic.D. Psychosomatic.（分数：1.00）A.B.C.D.14.The nurse observes that the clients total parenteral nutrition (TPN) solution is i
17、nfusing too slowly. The nurse calculates that the client has received 300 mL less than was ordered for the day. What should the nurse do next?A. Assess the infusion system, note the clients condition, and notify the physician.B. Discontinue the solution and administer dextrose in 5% water until the
18、infusion problem is resolved.C. Increase the flow rate to infuse an additional 300 mL over the next hour.D. Maintain the flow rate at the current rate and document any discrepancy in the chart.（分数：1.00）A.B.C.D.15.When caring for a client with ulcerative colitis, the nurse should include which of the
19、 following nursing interventions in the plan of care?A. Encouraging the use of stool softeners.B. Suggesting sitz baths as needed.C. Arrange for the client to have a private bathroom.D. Wearing a gown to provide direct care.（分数：1.00）A.B.C.D.16.The nurse discusses discharge plan with the parents of a
20、 child following a sickle cell crisis. Which of the following would the nurse emphasize the need to seek prompt health care?A. Headaches and nausea.B. Fatigue and lassitude.C. Skin rash and itching.D. Sore throat and fever.（分数：1.00）A.B.C.D.17.Which of the following factors would be most important in
21、 selecting the needle length to use for a subcutaneous injection of hydromorphone hydrochloride?A. The diameter of the needle.B. The amount of adipose tissue at the administration site.C. The amount of medication to be administered.D. The viscosity of the solution to be injected.（分数：1.00）A.B.C.D.18.
22、A woman who is 10 weeks pregnant complains about her fatigue and frequent urination. What would be the nurses response?A. Recognize these as normal early pregnancy signs and symptoms.B. Question her further about these signs and symptoms.C. Tell the client that shell need blood work and urinalysis.D
23、. Tell the client that she may be excessively worried.（分数：1.00）A.B.C.D.19.For which type of schizophrenia should the nurse expect to provide the most physical care?A. Disorganized type.B. Catatonic type.C. Paranoid type.D. Undifferentiated type.（分数：1.00）A.B.C.D.20.The nurse must assess judgment to d
24、etermine a clients mental status. Which test best accomplishes this?A. Interpreting proverbs.B. Spelling words backward.C. Counting by serial sevens.D. Discussing hypothetical ethical situations.（分数：1.00）A.B.C.D.21.The nurse is assessing a pregnant woman in the clinic. In the course of the assessmen
25、t, the nurse learns that this woman smokes one pack of cigarettes per day. Which of the following is the first step the nurse should take to help the woman stop smoking?A. Assess the clients readiness to stop.B. Suggest that the client reduce the daily number of cigarettes smoked by one-half.C. Prov
26、ide the client with the telephone number of a formal smoking-cessation program.D. Help the client develop a plan to stop.（分数：1.00）A.B.C.D.22.After teaching the mother about tests performed to monitor the success of the infants treatment for congenital hypothyroidism, the nurse would determine that t
27、he teaching was effective when the mother states that the child will need frequent blood tests and regular assessment of which of the following?A. Blood electrolyte levels.B. Metabolic rate.C. Muscular coordination.D. Bone age.（分数：1.00）A.B.C.D.23.A client diagnosed with hyperthyroidism has been star
28、ted on propylthiouracil (PTU) as drug therapy. The nurse should closely observe the client for which of the following side effects?A. Unusual bleeding or bruising.B. Hypertension.C. Hypokalemia.D. Peripheral edema.（分数：1.00）A.B.C.D.24.A client who suffered blunt chest trauma in a car accident complai
29、ns of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub-a classic sign of acute pericarditis. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position?A. Semi-Fowlers.B. Leanin
30、g forward while sitting.C. Supine.D. Prone.（分数：1.00）A.B.C.D.25.An 89-year-old client is suffering from dementia of the Alzheimers type. Which intervention would be most useful in managing his dementia?A. Provide a safe environment.B. Provide a stimulating environment.C. Avoid the use of touch.D. Use
31、 restraints whenever necessary.（分数：1.00）A.B.C.D.26.A client is diagnosed with a herniated lumbar disk at the L-5 interspace. Which of the following symptoms would most likely be the one that first caused the client to seek health care?A. Loss of voluntary muscle control.B. Loss of bladder control.C.
32、 Back pain that is relieved with resting.D. Back pain that radiates to the shoulders.（分数：1.00）A.B.C.D.27.A client who is a gravida 1 para 0 has been admitted to the perinatal admission unit and is in early labor. The clients cervical examination would reveal which of the following?A. 2 cm dilated; 1
33、00% effaced at 0 station.B. 4 to 5 cm dilated; 80% effaced at -1 station.C. 2 cm dilated; 50% effaced at +1 station.D. 3 cm dilated; 50% effaced at 0 station.（分数：1.00）A.B.C.D.28.Which of the following is NOT a contributory factor to thermoregulation in the preterm neonate?A. Immature central nervous
34、 system (CNS).B. Large skin surface area.C. Lack of subcutaneous (SC) and brown fat.D. Tendency toward capillary fragility.（分数：1.00）A.B.C.D.29.The nurse is caring for a client during the fourth stage of labor. Which of the following nursing interventions would be LEAST appropriate?A. Catheterization
35、 to protect the bladder from trauma.B. Perineal assessments for swelling and bleeding.C. Vital signs and fundal checks every 15 minutes.D. Time with the neonate to initiate breast-feeding.（分数：1.00）A.B.C.D.30.Which of the following is normal neonate calorie intake?A. 90 to 100 calories per kilogram.B
36、. 110 to 130 calories per kilogram.C. 30 to 40 calories per lb of body weight.D. At least 2mL per feeding.（分数：1.00）A.B.C.D.二、Part Two(总题数：23，分数：23.00)31.An adolescent client immobilized in a spica cast complains of having trouble breathing after meals. Which of the following actions would be best?A.
37、 Encourage the client to drink more between meals.B. Teach the adolescent purse you dont have to worry. “B. “You practice good health habits; just follow them and youll be fine. “C. “There is nothing you can do to have a healthy pregnaney; its all up to nature. “D. “Folic acid, 400 mcg(1mcg= 10g), i
38、mproves pregnancy outcomes by preventing certain complications. /（分数：1.00）A.B.C.D.41.The client with a total laryngectomy receives tube feedings to meet his fluid and nutrition needs. The nurse explains to the client that the purpose of the tube feedings is toA. prevent pain from swallowing.B. preve
39、nt fistula development.C. ensure adequate intake.D. allow for adequate suture line healing.（分数：1.00）A.B.C.D.42.Following a precipitous delivery, examination of the clients vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client?A. Applyi
40、ng cold to limit edema during the first 12 to 24 hours.B. Instructing the client on the use of sitz-baths if ordered.C. Instructing the client about the importance of perineal (Kegel) exercises.D. Instructing the client to use two or more peripads to cushion the area.（分数：1.00）A.B.C.D.43.A client has
41、 a total serum cholesterol level of 326 mg/dL. The nurse explains to the client that this levelA. is normal and requires no further treatment.B. is high and will require dietary modification.C. is low and requires no further treatment.D. is borderline normal and may require dietary modification.（分数：
42、1.00）A.B.C.D.44.Which of the following should the nurse include in a postoperative teaching plan for a client with a laryngectomy?A. Telling the client to speak by covering the stoma with a sterile gauze pad.B. Reassuring the client that normal eating will be possible after healing has occurred.C. I
43、nstructing the client to avoid coughing until the sutures are removed.D. Instructing the client to control oral secretions by swabbing them with tissues or by expectorating into an emesis basin.（分数：1.00）A.B.C.D.45.The nurse is developing a plan of care for a client with iron-deficiency anemia. Which
44、 of the following would be an appropriate nursing diagnosis of the client?A. Excess fluid volume related to anemia.B. Imbalanced nutrition related to nausea.C. Activity intolerance related to fatigue.D. Impaired home maintenance related to neurological impairment.（分数：1.00）A.B.C.D.46.When caring for
45、a client during the second stage of labor, which action would be least appropriate?A. Assisting the client with pushing.B. Ensuring the clients legs are positioned appropriately.C. Allowing the client clear liquids.D. Monitoring the fetal heart rate.（分数：1.00）A.B.C.D.47.A few days after a colectomy,
46、a client suddenly develops chest pain, shortness of breath, and air hunger. The nurse knows she must further assess the clients chest pain to determine its origin. When determining whether the chest pain is cardiac or pleuritic in nature, the nurse knows that pleuritic chest pain typicallyA. is desc
47、ribed as crushing and substernal.B. worsens with deep inspiration.C. is relieved with nitroglycerin.D. is relieved when the client leans forward.（分数：1.00）A.B.C.D.48.The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development?A. Has perceptions bas
48、ed on reality.B. Assumes responsibility for actions.C. Generates new levels of awareness.D. Has maximum ability to solve problems and learn new skills.（分数：1.00）A.B.C.D.49.The nurse notices muscle twitching in the hands and forearms of the client with pancreatitis. The nurse would report these sympto
49、ms immediately because clients with pancreatitis are at serious risk for which of the following problems?A. Hypermagnesemia.B. Hyperkalemia.C. Hypoglycemia.D. Hypocalcemia.（分数：1.00）A.B.C.D.50.A 14-year-old girl with Type 1 diabetes is monitoring her blood glucose level at home. Which of the following actions indicates that she understands appropriate care management strategies for a blood glucose level of 250 mg/dL?A. She will skip the next dose of insulin and drink fruit juice.B. She will take insulin and drink water.C. She will eat a high-carbohydrate meal and exerci
