1、美国护士资格认证(CGFNS)-23 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 interventions will assist the client in taking phenytoin as prescribed?A. Calling him daily for the first week after hospital discharge.B. Having a family member monitor him to ensure compliance.C. Provi
2、ding him with written and verbal instructions about the medicine.D. Emphasizing that embarrassing seizures may occur again if he does not take the medicine.（分数：1.00）A.B.C.D.2.Which of the following signs or symptoms would the nurse expect to see in a client with pancreatitis?A. Bradycardia.B. Hypert
3、ension.C. Decreased white blood cell count.D. Left upper quadrant abdominal pain.（分数：1.00）A.B.C.D.3.Mrs. Wilson, a primigravida, was admitted to the hospital at 12 weeks gestation. She is complaining of abdominal cramping, exhibits bright red vaginal spotting without cervical dilation. The nurse det
4、ermines that the client is most likely experiencing which of the following types of abortion?A. Complete.B. Threatened.C. Inevitable.D. Missed.（分数：1.00）A.B.C.D.4.The nurse is assessing a 15-year-old female who is being admitted for treatment of anorexia nervosa. Which of the following clinical manif
5、estation is the nurse most likely to find from the client?A. Tachycardia.B. Coarse hair growth.C. Parotid gland tenderness.D. Warm, flushed extremities.（分数：1.00）A.B.C.D.5.A priority nursing diagnosis during the first 24 hours following an MI isA. Ineffective cardiac tissue perfusion.B. Risk for infe
6、ction.C. Deficient fluid volume.D. Constipation.（分数：1.00）A.B.C.D.6.The parents of a 3-year-old boy call the clinic to report chickenpox. When teaching the parents about how to care for the lesions, the nurse would advise which of the following?A. Soak in a hot tub for 30 minutes three times a day.B.
7、 Take an antihistamine and use calamine lotion on the lesions.C. Take acetaminophen and use an antibiotic ointment on the lesions.D. Remove lesions crusts as they form.（分数：1.00）A.B.C.D.7.Which of the following nursing diagnoses would be most appropriate when teaching the mother of a toddler?A. Activ
8、ity intolerance.B. Risk for injury.C. Delayed growth and development.D. Impaired mobility.（分数：1.00）A.B.C.D.8.Pancrelipase (Viokase), an enzyme replacement, has been prescribed for a client with chronic pancreatitis. The nurse evaluates the clients understanding of how to take this drug. Which of the
9、 following statements indicates the client has adequate knowledge?A. “The enzyme mixture should be taken after each meal. “B. “The enzyme mixture should be stored in the refrigerator to keep it fresh. “C. “I should be careful not to inhale the powder when mixing it with food. “D. “I should chew the
10、capsule thoroughly. /（分数：1.00）A.B.C.D.9.Which of the following serum electrolyte levels would the nurse expect to find in an infant with persistent vomiting?A. K+, 3.2 mEq/L; Cl-, 92 mEq/L; Na+, 120 mEq/L.B. K+, 3.4 mEq/L; Cl-, 120 mEq/L; Na+, 140 mEq/L.C. K+, 3.5 mEq/L; Cl-, 90 mEq/L; Na+, 145 mEq/
11、L.D. K+, 5.5 mEq/L; Cl-, 110 mEq/L; Na+, 130 mEq/L.（分数：1.00）A.B.C.D.10.Which one of the following nursing interventions should be included in a plan of care for a client with a T tube?A. Maintain client in a supine position while T tube is in place.B. Keep T tube clamped except for during mealtimes.
12、C. Inspect skin around the T tube daily for irritation.D. Irrigate the T tube every 4 hours to maintain patency.（分数：1.00）A.B.C.D.11.When instructing the client with severe burns about proper nutrition, the nurse would encourage him to eat which of the following meals?A. Chicken breast, salad, iced t
13、ea.B. Roast beef sandwich, milkshake, cottage cheese.C. Hamburger, orange, coffee.D. Pasta salad, carrots, iced tea.（分数：1.00）A.B.C.D.12.The nurse evaluates the clients understanding of myasthenia gravis. The nurse would judge that the client has formed a realistic concept of her condition when she s
14、aysA. “By taking medication and pacing activities, I will live longer, but ultimately the disease will cause my death. “B. “By taking medication and pacing activities, my fatigue will be relieved, but I should expect occasional periods of muscle weakness. “C. “By taking medication and pacing activit
15、ies, my symptoms will be controlled and eventually the disease will be cured. “D. “By taking medication and pacing activities, I should be able to control the disease and enjoy a healthy lifestyle. /（分数：1.00）A.B.C.D.13.The nurse has assisted a multigravida with a precipitous delivery of a viable neo
16、nate in a local grocery store. Because a precipitous delivery can lead to decreased uterine tone, which of the following nursing actions would help to prevent this complication?A. Place the neonate on the clients fundus.B. Place the mother in a supine position.C. Encourage the mother to breast-feed
17、the infant.D. Massage the clients fundus continuously.（分数：1.00）A.B.C.D.14.The nurse is caring for a client who has generalized anxiety disorder. Which statement is true about this client?A. The client has regular obsessions.B. Relaxation techniques and psychotherapy are necessary for cure.C. Nightma
18、res and flashbacks are common in individuals who suffer from generalized anxiety disorder.D. Generalized anxiety disorder is characterized by anxiety that lasts longer than 6 months.（分数：1.00）A.B.C.D.15.The nurse is preparing a gastric lavage for a comatose victim of the car accident. Which of the fo
19、llowing positions would be most appropriate for the client during this procedure?A. Trendelenburgs.B. Lithotomy.C. Lateral.D. Supine.（分数：1.00）A.B.C.D.16.A pregnant client who is diabetic is at risk for having a large-for-gestational-age infant because of which of the following?A. Excess sugar causin
20、g reduced placental functioning.B. Insulin acting as a growth hormone on the fetus.C. Maternal dietary intake of high calories.D. Excess insulin reducing placental functioning.（分数：1.00）A.B.C.D.17.Which of the following findings is suggestive of myocardial infarction (MI)?A. Below-normal erythrocyte
21、sedimentation rate.B. Elevated white blood cell count.C. Elevated serum cholesterol value.D. Elevated creatine phosphokinase (CPK) value.（分数：1.00）A.B.C.D.18.When helping the client who has had a cerebrovascular accident (CVA) learn self-care skills, the nurse should use which of the following interv
22、entions to help him learn to dress himself?A. Encourage the client to wear clothing designed especially for people who have had a CVA.B. Dress the client, explaining each step of the process as it is completed.C. Teach the client to put on clothing on the affected side first.D. Encourage the client
23、to ask his wife for help when dressing.（分数：1.00）A.B.C.D.19.Susan is an adolescent client with pregnancy-induced hypertension (PIH). The physician orders 5% dextrose in Ringers solution and magnesium sulfate intravenously for her. Before the magnesium sulfate is administered, which of the following a
24、ssessments would be the priority?A. Maternal urinary output.B. Fetal position.C. Fetal heart rate variability.D. Maternal respiratory rate.（分数：1.00）A.B.C.D.20.A client with heart failure loses 3.2 kg while hospitalized. Approximately how many pounds has the client lost?A. 1 pound.B. 3 pounds.C. 5 po
25、unds.D. 7 pounds.（分数：1.00）A.B.C.D.21.Which of the following health-promoting activities should the nurse teach the client with a new laryngectomy?A. Cleanse the mouth three times a day.B. Avoid taking tub baths.C. Develop an aggressive program of exercise to increase airway functioning.D. Dehumidify
26、 the air for comfort.（分数：1.00）A.B.C.D.22.The community health nurse develops a health education program about preventing the transmission of hepatitis B. The nurse evaluates that the teaching has been effective when the community residents identify which of the following activities to be high risk f
27、or acquiring hepatitis B?A. Sharing needles for drug use.B. Ingestion of contaminated seafood.C. Frequent use of marijuana.D. Ingestion of large amounts of acetaminophen (Tylenol).（分数：1.00）A.B.C.D.23.Which of the following is an early sign of laryngeal cancer?A. Difficulty swallowing.B. Chronic foul
28、 breath.C. Persistent mild hoarseness.D. Nagging unproductive cough.（分数：1.00）A.B.C.D.24.Mrs. Cray, an African American, is admitted to the hospital after sustaining a hip fracture. She is 5 ft. , 4 inches tall and weighs 96 lbs. She has five children and has used estrogen replacement therapies for 1
29、0 years. She told the nurse that she “just stepped forward and fell. “ The results of her bone density tests indicate she has osteoporosis. Which of the following is the greatest risk factor for osteoporosis for this woman?A. Her long-term use of estrogen.B. Her weight.C. Her family.D. Her race.（分数：
30、1.00）A.B.C.D.25.Which of the following would be an appropriate expected outcome of nursing care for the client with ulcerative colitis?A. The client experiences decreased frequency of constipation.B. The client accepts that an ileostomy will be necessary.C. The client maintains an ideal body weight.
31、D. The client verbalizes the importance of restricting fluids.（分数：1.00）A.B.C.D.26.Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt?A. Monitoring intake and output.B. Allowing the infant to rest undisturbed.C. P
32、roviding age-appropriate diversionary activities.D. Initiating oral feedings.（分数：1.00）A.B.C.D.27.A pregnant client with premature rupture of the membranes has had contractions every 10 minutes. After 48 hours, the contractions stop and the client is to be discharged with home monitoring. The nurse d
33、iscusses with the client about preterm labor symptoms. Which of the following statements made by the client indicates that she needs further instruction?A. “I should report contractions that occur every 10 minutes in 1 hour. “B. “I should lie in bed on my left side if contractions begin. “C. “I shou
34、ld call the doctor if my contractions occur every hour for 6 hours. “D. “If I start having contractions, I should empty my bladder. /（分数：1.00）A.B.C.D.28.The nurse is assessing a client with an ileal conduit. She notes that the clients urinary appliance contains pale yellow urine with large amounts o
35、f mucus. How would the nurse best interpret these data?A. These findings are normal for the client.B. There is irritation of the stoma.C. The client is developing an infection of the urinary tract.D. The mucus is caused by elevated levels of glucose in the urine.（分数：1.00）A.B.C.D.29.A primigravida at
36、 28 weeks gestation is admitted with a diagnosis of preterm labor. The clients contractions are occurring every 15 to 20 minutes, lasting 25 seconds. The membranes are intact. What should the nurse do?A. Request assistance from the neonatal resuscitation team.B. Place the client on bed rest on her l
37、eft side.C. Obtain equipment for an amniotomy.D. Prepare terbutaline in an intravenous solution of normal saline.（分数：1.00）A.B.C.D.30.The nurse notices that a depressed client taking amitriptyline (Elavil) for 2 weeks has become very outgoing, cheerful, and talkative. The nurse would suspect which of
38、 the following?A. The client is responding to the antipsychotic.B. The client may be experiencing increased energy and is at an increased risk for suicide.C. The client is ready to be discharged from treatment.D. The client is experiencing a split personality.（分数：1.00）A.B.C.D.二、Part Two(总题数：23，分数：23
39、.00)31.The immobile adolescent with a recent fractured femur suddenly complains chest pain, dyspnea, diaphoresis, and tachycardia. Which of the following would the nurse suspect?A. Atelectasis.B. Pneumonia.C. Pulmonary edema.D. Pulmonary emboli.（分数：1.00）A.B.C.D.32.A primigravida at 34 weeks gestatio
40、n is diagnosed with hydramnios. After delivery of the neonate, a priority for the nurse is to assess the neonate for which problem?A. Kidney disorders.B. Cardiac defects.C. Diabetes mellitus.D. Esophageal atresia.（分数：1.00）A.B.C.D.33.Which of the following signs and symptoms would be an early indicat
41、ion that the clients serum potassium level is below normal?A. Diarrhea.B. Tingling in the fingers.C. Sticky mucous membranes.D. Muscle weakness in the legs.（分数：1.00）A.B.C.D.34.A breast-feeding neonate will turn his head toward the mothers breast in a natural instinct to find food. What is the name o
42、f this reflex?A. Tonic neck reflex.B. Moros reflex.C. Grasp reflex.D. Rooting reflex.（分数：1.00）A.B.C.D.35.Which abnormal laboratory value is most indicative of aplastic anemia?A. A decreased hemoglobin.B. An elevated white blood cell count.C. An elevated red blood cell count.D. A decreased erythrocyt
43、e sedimentation rate.（分数：1.00）A.B.C.D.36.The nurse observes that a depressed client has bathed, is wearing a clean blouse and slacks, and has combed her hair. Which statement by the nurse would be most helpful for the client?A. “I like your blouse and slacks. “B. “You look good today. “C. “Im glad y
44、oure feeling better today. “D. “Im glad you combed your hair today. /（分数：1.00）A.B.C.D.37.The clinic nurse is instructing a group of parents about emergency treatment for accidental poisoning and injury. Which of the following statements by one of the mothers indicates that she needs further instruct
45、ion?A. “I should flush my childs eye with room temperature tap water for 15 to 20 minutes if a caustic material gets into it. “B. “I should save the emesis if my child vomits. “C. “I should call the poison control center if there are any symptoms. “D. “I should give 2 to 5 teaspoons of clear fluids
46、after administering ipecac. /（分数：1.00）A.B.C.D.38.During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the intravenous infusion rate will be adjusted by evaluating which of the following observation?A. Daily body weight.B. Hourly urine output.C. Hourly urine speci
47、fic gravity.D. Hourly body temperature.（分数：1.00）A.B.C.D.39.The client complains a continuous bladder irrigation after a transurethral resection. Which of the following is the major goal of nursing interventions related to the irrigation?A. Recognize signs of prostate cancer.B. Perform activities of
48、daily living.C. Maintain catheter patency.D. Reduce incisional bleeding.（分数：1.00）A.B.C.D.40.Which of the following signs and symptoms is classic for a patient with rheumatoid arthritis?A. Joint swelling, joint stiffness in the morning, and bilateral joint involvement.B. Crepitus, development of Hebe
49、rdens nodes, and anemia.C. Pain on weight-bearing, rash, and low-grade fever.D. Fatigue, leukopenia, and joint pain.（分数：1.00）A.B.C.D.41.A 28-year-old client delivered a full-term male neonate one hour ago. Which finding should the nurse expect when palpating the clients fundus?A. Soft, at the level of the umbilicus.B. Firm, 2 cm below the umbilicus.C. Firm, at the level of the umbilicus.D. Boggy, midway between the umbilicus and symphysis pubis.（分数：1.00）A.B.C.D.42.When caring for a client who has had a cesarean birth, which of the following nursing interventions is least ap
