【医学类职业资格】美国护士资格认证(CGFNS)-13及答案解析.doc

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1、美国护士资格认证(CGFNS)-13 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 in her 36th week of pregnancy is admitted to the hospital with vaginal bleeding. After undergoing an ultrasonic scan, shes diagnosed with placenta previa. Which assessment finding would best confirm this diagnosis?A.

2、A rigid abdomen.B. A soft, nontender uterus.C. Painful vaginal bleeding.D. Hypotension.（分数：1.00）A.B.C.D.2.The nurse is providing care for an immobilized client. For this client, the most appropriate and most effective nursing intervention would beA. getting the client out of bed and into a chair for

3、 30 minutes, twice daily.B. avoiding repositioning the client if hes comfortable.C. repositioning the client on alternate sides at least every 2 hours.D. positioning the client with the greatest pressure at the bony prominence.（分数：1.00）A.B.C.D.3.A client hospitalized with pneumonia has thick, tenaci

4、ous secretions. To help liquefy these secretions, the nurse shouldA. turn the client every 2 hours.B. elevate the head of the bed 30 degrees.C. encourage increased fluid intake.D. maintain a cool room temperature.（分数：1.00）A.B.C.D.4.The nurse is interviewing a 19-year-old female at a clinic. Its her

5、first visit, and she says that she has been exposed to herpes by her boyfriend. Initially, with primary genital or type 2 herpes simplex, the nurse would expect the client to haveA. burning or tingling on the vulva, perineum, or vagina.B. dysuria and urine retention.C. perineal ulcers and erosions.D

6、. bilateral inguinal lymphadenopathy.（分数：1.00）A.B.C.D.5.The nurse is caring for a neonate with a myelomeningocele. The priority nursing care of a neonate with a myelomeningocele is primarily directed towardA. ensuring adequate nutrition.B. preventing infection.C. promoting neural tube sac drainage.D

7、. conserving body heat.（分数：1.00）A.B.C.D.6.The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. What is a major complication of TPN?A. Hyperglycemia.B. Extreme hunger.C. Hypotension.D. Hypoglycemia.（分数：1.00）A.B.C.D.7.The nurse is assessing

8、a neonate. Health history findings indicate that the mother drank 3 oz (88.7mL) or more of alcohol per day throughout her pregnancy. Which characteristic should the nurse expect to find?A. Prominent nasal bridge.B. Thick upper lip.C. Upturned nose.D. Large for gestational age.（分数：1.00）A.B.C.D.8.The

9、nurse has a client at 30 weeks gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when she says that she wants to breast-feed her neonate?A. Encourage breas-feeding so that she can get her rest and get healthier.B. Encourage breast-fee

10、ding because its healthier for the neonate.C. Encourage breast-feeding to facilitate bonding.D. Discourage breast-feeding because HIV can be transmitted through breast milk.（分数：1.00）A.B.C.D.9.The nurse walks into the room of a client who has had surgery for testicular cancer. The client says that he

11、ll be undesirable to his wife, and he becomes tearful. He expresses that hes spoiled a happy, satisfying sex life with his wife, and says that he thinks it might be best if he would just die. Based on these signs and symptoms, which nursing diagnosis would be most appropriate for planning purposes?A

12、. Situational low self-esteem.B. Unilateral neglect.C. Social isolation.D. Risk for loneliness.（分数：1.00）A.B.C.D.10.The nurse is caring for a client who is in labor. The physician still isnt present. After the neonates head is delivered, which nursing intervention would be most appropriate?A. Checkin

13、g for the umbilical cord around the neonates neck.B. Placing antibiotic ointment in the neonates eyes.C. Turning the neonates head to the side, to drain secretions.D. Assessing the neonate for respirations.（分数：1.00）A.B.C.D.11.The nurse is administering sublingual nitroglycerin to a client with chest

14、 pain. The nurse should place the medicationA. in the cheek.B. on the tip of the tongue.C. under the tongue.D. under the lower lid of the eye.（分数：1.00）A.B.C.D.12.The nurse is preparing to remove a previously applied topical medication from a client. The rationale for removing previously applied topi

15、cal medications before applying new medications is toA. decrease the possibility of absorption on the nurses skin.B. allow distribution of medication.C. prevent soiling of the clients clothes.D. avoid administering more than the prescribed dose.（分数：1.00）A.B.C.D.13.A client with acute respiratory fai

16、lure is intubated and placed on mechanical ventilation. Which intervention is most appropriate when suctioning the client?A. Insert the suction catheter while applying suction.B. Apply suction until all the secretions have been removed.C. Use the same catheter to first suction the mouth, then the en

17、dotraeheal tube.D. Preoxygenate with 100% oxygen before suctioning.（分数：1.00）A.B.C.D.14.A nurse in the nursery is preparing to perform phenylketonuria (PKU) testing. Which neonate is ready for the nurse to test?A. A 3-day-old neonate who has been fed IV since birth.B. A 2-day-old neonate who has been

18、 breast-fed.C. A 1-day-old neonate receiving formula.D. A breast-fed neonate being discharged within 24 hours of birth.（分数：1.00）A.B.C.D.15.The nurse is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication?A. Bon

19、e fracture.B. Loss of estrogen.C. Negative calcium balance.D. Dowagers hump.（分数：1.00）A.B.C.D.16.Every morning a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain?A. 70 units of NPH insulin and 30 units of regular insulin.B. 70 units of regular ins

20、ulin and 30 units of NPH insulin.C. 70% NPH insulin and 30% regular insulin.D. 70% regular insulin and 30% NPH insulin.（分数：1.00）A.B.C.D.17.A high school student is referred to the school nurse for suspected substance abuse. Following the nurses assessment and interventions, what would be the most de

21、sirable outcome?A. The student discusses conflicts over drug use.B. The student accepts a referral to a substance abuse counselor.C. The student agrees to inform his parents of the problem.D. The student reports increased comfort with making choices.（分数：1.00）A.B.C.D.18.A client is admitted for detox

22、ification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but that he can control his use if he chooses. Which coping mechanism is he using?A. Withdrawal.B. Logical thinking.C. Repression.D. Denial.（分数：1.00）A.B.C.D.19.The nurse is assessing a client with possible

23、 osteoarthritis. The most significant risk factor for osteoarthritis isA. congenital deformity.B. age.C. trauma.D. obesity.（分数：1.00）A.B.C.D.20.Drugs to treat acute anxiety are prescribed to a client hospitalized for an acute myocardial infarction. The client is reluctant to take anti-anxiety drugs.

24、The nurse suspects that the client is holding the drugs under his tongue and disposing of them after she has left the room. What should the nurse do first?A. Report her suspicions to the clients physician.B. Talk to the client about his attitude toward the medications.C. Search the clients room for

25、evidence of the medications.D. Tell the client that his behavior must stop for his own well-being.（分数：1.00）A.B.C.D.21.Which of the following statements about external otitis is true?A. External otitis is eharaeterized by pain when the pinna of the ear is pulled.B. External otitis is usually accompan

26、ied by a high fever in children.C. External otitis is usually related to an upper respiratory infection.D. External otitis can be prevented by using cotton-tipped applicators to clean the ear.（分数：1.00）A.B.C.D.22.A client with heart failure develops pink frothy sputum, coarse crackles, and restlessne

27、ss. Which of the following actions should the nurse take first?A. Check the clients blood pressure.B. Place the client in high Fowlers position.C. Calculate the clients fluid balance.D. Notify the physician.（分数：1.00）A.B.C.D.23.The nurse is teaching a client with a history of atherosclerosis. To decr

28、ease 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.24.A client with type 1 diabetes mellitus is pregnant for the second time. He

29、r previous pregnancy ended in spontaneous abortion at 18 weeks gestation. Shes now at 22 weeks gestation. The nurse is responsible for teaching the client about exercise during her pregnancy. Which of the following statements indicates that the client has an appropriate understanding of her exercise

30、 needs?A. “I know I need to walk with a friend or family member. “B. “I know I need to vary the times of day when I exercise. “C. “I know I need to exercise before meals. “D. “I know I need to drink fluids while I walk. /（分数：1.00）A.B.C.D.25.Which of the following positions is most appropriate for a

31、neonate with congenital hip dislocation?A. Semi-Fowlers with both legs flexed.B. Legs adducted with head elevated.C. Swaddled in a baby carrier.D. Prone position with hips abducted.（分数：1.00）A.B.C.D.26.The nurse is admitting a client with a suspected fluid imbalance. The most sensitive indicator of b

32、ody fluid balance isA. daily weight.B. serum sodium levels.C. measured intake and output.D. blood pressure.（分数：1.00）A.B.C.D.27.The nurse is caring for a client with a fractured hip. The client is combative and confused, and hes trying to get out of bed. The nurse shouldA. leave the client and get he

33、lp.B. obtain a physicians order to restrain the client.C. read the facilitys policy on restraints.D. order soft restraints from the storeroom.（分数：1.00）A.B.C.D.28.The nurse is caring for a client with adult respiratory distress syndrome (ARDS). What is the most likely laboratory finding in the early

34、stages of this disease?A. Increased carboxyhemoglobin.B. Decreased partial pressure of arterial oxygen (PaO2).C. Increased partial pressure of arterial carbon dioxide (PaCO2).D. Decreased bicarbonate ( （分数：1.00）A.B.C.D.29.A 78-year-old client with sensorineural hearing loss is admitted to a rehabili

35、tation center after hip replacement surgery. A risk factor for this client would beA. altered perceptions.B. toxic levels of pain medication.C. impaired cognitive function.D. impaired sense of time.（分数：1.00）A.B.C.D.30.The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours ear

36、lier. The client has a nasogastric (NG) tube. The nurse shouldA. apply suction to the NG tube every hour.B. clamp the NG tube if the client complains of nausea.C. irrigate the NG tube gently with normal saline solution.D. reposition the NG tube if pulled out.（分数：1.00）A.B.C.D.二、Part Two(总题数：23，分数：23.

37、00)31.A 28-year-old single female arrives at a mental health clinic complaining of depression. She states that she has been feeling numb and empty most of the time and has little energy to perform her usual activities. She has experienced these difficulties since the death of her best friend 6 month

38、s ago. Which of the following is the nurses best response?A. Tell the client that the physician will prescribe an antidepressant and she will feel better.B. Encourage the client to get on with her life and stop feeling sorry for herself.C. Advise the client that it isnt unusual for grieving and loss

39、 to continue for quite some time.D. Suggest that the client return in 3 months if the feelings persist.（分数：1.00）A.B.C.D.32.A client in the manic phase of bipolar disorder constantly belittles other clients and demands special favors from the nurses. Which nursing intervention would be most appropria

40、te for this client?A. Ask other clients and staff members to ignore the clients behavior.B. Set limits with consequences for belittling or demanding behavior.C. Offer the client an antianxiety drug when belittling or demanding behavior occurs.D. Offer the client a variety of stimulating activities t

41、o distract him from belittling or making demands of others.（分数：1.00）A.B.C.D.33.The nurse is caring for a client with a fractured left femur. What signs indicate potential fat emboli?A. Increased partial pressure of arterial oxygen (PaO2), reduced sensation in left leg or foot.B. Left leg pain, dyspn

42、ea.C. Bradycardia, skin bruises.D. Cyanosis, decreased PaO2.（分数：1.00）A.B.C.D.34.The nurse is caring for an 85-year-old client. For which important factor directly influencing this clients mental health should the nurse be most aware?A. The clients attitude toward life circumstances.B. The clients ag

43、e, education level, social status, and economic level.C. The number of children and grandchildren in the family and the clients relationship with them.D. Grief issues related to loss, role changes, and physical stamina.（分数：1.00）A.B.C.D.35.A mother brings her 15-month-old male child to the ambulatory

44、 care clinic for well-child care. Hes crying and pulling at his left ear, which appears erythematous. Which of the following actions should the nurse take first?A. Ask the mother to leave the room because her anxiety is increasing the childs distress.B. Examine the ear with the child supine because

45、this aids visualization of the tympanic membrane.C. Examine the affected ear last in order to minimize distress early in the examination.D. Examine the left ear first in order to assess what may be physically wrong with the child.（分数：1.00）A.B.C.D.36.The nurse is providing preoperative care to a clie

46、nt scheduled for an appendectomy. Which statement regarding pain control is most appropriate?A. “Theres no need to ask for pain medication, youll receive it on a schedule. “B. “Take your pain medication after walking so that you wont feel dizzy. “C. “Take your pain medication before your pain become

47、s intense. “D. “Use as little pain medication as possible to avoid addiction. /（分数：1.00）A.B.C.D.37.During afternoon rounds, the nurse finds a male client using a pencil to scratch inside his knee-to-toe cast. The client is complaining of severe itching in the ankle area. Which action should the nurs

48、e take?A. Allow him to continue to scratch inside the cast with a pencil.B. Give him a sterile metal object to use for scratching instead of the pencil.C. Encourage him to avoid scratching, and obtain an order for diphenhydramine (Benadryl) if severe itching persists.D. Obtain an order for a sedativ

49、e, such as diazepam (Valium), to prevent him from scratching.（分数：1.00）A.B.C.D.38.While making rounds in a senior citizens housing complex, the visiting nurse discovers one of her clients sobbing in her darkened apartment. On questioning the client, an 85- year-old widow, the nurse learns that her pet cat of 15 years had been put to sleep the day before. Whats the nurses best response?A. “It shouldnt be hard to find another cat. Youll feel better once you have another pet. “B. “It was only a cat. Why are you allowing yourself to be so upset? It would