1、美国护士资格认证(CGFNS)-27 及答案解析(总分：50.00，做题时间：90 分钟)一、BPart One/B(总题数：30，分数：30.00)1.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 to protect the bladder from trauma. B. Perineal assessments for
2、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.2.The nurse is providing home care to a client with failing vision due to macular degeneration. The nurse is concerned about the clients safety. Which of the
3、 following activities would help to lessen the clients risk of falling? A. Arranging pieces of furniture close together so the client can use them for guidance and support. B. Encouraging the client to wear a medical identification bracelet that describes the clients visual deficit. C. Installing a
4、flashing light to indicate when the phone or doorbell is ringing. D. Installing handrails in hallways, in bathrooms, and on steps.（分数：1.00）A.B.C.D.3.Mrs. S with preterm labor will be under Terbutaline (Brethine) therapy. Before beginning the therapy, which of the following assessments would be most
5、important? A. Estimated fetal size. B. Maternal heart rate. C. Contraction intensity. D. Deep tendon reflexes.（分数：1.00）A.B.C.D.4.Which of the following should be the nurses initial action immediately following the birth of the neonate? A. Aspirating mucus from the neonates nose and mouth. B. Drying
6、the infant to stabilize the neonates temperature. C. Promoting parental bonding. D. Identifying the neonate.（分数：1.00）A.B.C.D.5.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 pounds. D. 7 pounds.（分数：1.00）A.
7、B.C.D.6.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 with intrauterine growth retardation.（分数：1.00）A.B.C.D.7.The
8、nurse is caring for a client who complains of lower back pain. Which instructions should the nurse give to this client to prevent back injury? A. Bend over the object youre lifting. B. Narrow the stance when lifting. C. Push or puI1 an object using your arms. D. Stand close to the object youre lifti
9、ng.（分数：1.00）A.B.C.D.8.A client asks the nurse what PSA is. The nurse should reply that it stands for A. prostate-specific antigen, used to screen for prostate cancer. B. protein serum antigen, used to determine protein levels. C. pneumococcal strep antigen, a bacteria that causes pneumonia. D. papan
10、icolaou-specific antigen, used to screen for cervical cancer.（分数：1.00）A.B.C.D.9.The nurse caring 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
11、mechanism. B. High hemoglobin (Hb) levels between 14 and 20 g/dL per 100 mL of blood. C. Persistent fetal circulation. D. Large, immature liver.（分数：1.00）A.B.C.D.10.For a client in addisonian crisis, it would be very risky for a nurse to administer A. potassium chloride. B. normal saline solution. C.
12、 hydrocortisone. D. fludrocortisone.（分数：1.00）A.B.C.D.11.A client with cholecystitis is receiving propantheline bromide. The client is given this medication because it A. reduces gastric solution production and hypermobility. B. slows emptying of the stomach and reduces chyme in the duodenum. C. inhi
13、bits contraction of the bile duct and gallbladder. D. decreases bile secretions.（分数：1.00）A.B.C.D.12.In an industrial accident, a client who weighs 155 lb (70.3 kg) sustained full-thickness burns over 40% of his body. Hes in the burn unit receiving fluid resuscitation. Which observation shows that th
14、e fluid resuscitation is benefiting the client? A. A urine output consistently above 100 mL/hr. B. A weight gain of 4 lb (1.8 kg) in 24 hours. C. Body temperature readings all within normal limits. D. An electrocardiogram (ECG) showing no arrhythmias.（分数：1.00）A.B.C.D.13.A client who has a potassium
15、level of 6 mEq/L should be treated with A. antacids. B. IV fluids. C. fluid restriction. D. sodium polystyrene sulfonate (Kayexalate).（分数：1.00）A.B.C.D.14.A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an IV infusion of oxytocin (Pitocin). Whic
16、h of the following is LEAST likely to be included in her plan of care? A. Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes. B. Allowing the client to ambulate as tolerated. C. Helping the client use breathing exercises to manage her contractions. D. Carefully
17、titrating the oxytocin based on her pattern of labor.（分数：1.00）A.B.C.D.15.Which of the following is an early sign of laryngeal cancer? A. Difficulty swallowing. B. Chronic foul breath. C. Persistent mild hoarseness. D. Nagging unproductive cough.（分数：1.00）A.B.C.D.16.The nurse is caring for a client wi
18、th left-sided heart failure. To reduce fluid volume excess, the nurse can anticipate using A. antiembolism stockings. B. oxygen. C. diuretics. D. anticoagulants.（分数：1.00）A.B.C.D.17.Which of the following statements about external otitis is true? A. External otitis is eharaeterized by pain when the p
19、inna of the ear is pulled. B. External otitis is usually accompanied 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.18.After 5 days of hospi
20、talization, the client who is receiving morphine sulfate for pain control asks for more pain medication with increasing frequency and exhibits increased anxiety and restlessness. His physical condition is stable. What is the probable cause of his behavior? A. His morphine dosage is too high. B. His
21、coping mechanisms are exhausted. C. He is becoming addicted to the narcotic. D. He has developed tolerance to his narcotic dosage.（分数：1.00）A.B.C.D.19.As part of the annual health screening, the nurse visits the eighth-grade physical education classes and asks each student to bend forward at the wais
22、t with the back parallel to the floor and the hands together at midline. For which of the following is the nurse assessing? A. Slipped epiphysis. B. Developmental dysplasia of hip. C. Idiopathic scoliosis. D. Physical dexterity.（分数：1.00）A.B.C.D.20.Nursing care for a client after electroeonvulsive th
23、erapy (ECT) should include which of the following? A. Nothing by mouth for 24 hours after the treatment because of the anesthetic agent. B. Bed rest for the first 8 hours after a treatment. C. Assessment of short-term memory loss. D. No special care.（分数：1.00）A.B.C.D.21.The nurse is caring for a clie
24、nt who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mmHg and he complains of dizziness. Which medication would be used to treat his bradycardia? A. Atropine. B. Dobutamine (Dobutrex). C. Bretylium (Bretylol). D. Lidocaine (Xylocaine).（分数：1.00）A.
25、B.C.D.22.A 23-month-old child is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress? A. Intercostal retractions. B. Bradycardia. C. Decreased level of consciousness. D. Flushed skin.（分数：1.00）A.B.C.D.23.Which of the following ho
26、me regimens should the nurse suggest to relieve itching in children with chicken pox? A. Generous amounts of fine baby powder. B. Oatmeal preparation baths. C. Terrycloth towels moistened with hydrogen peroxide. D. Cool compresses moistened with a weak salt solution.（分数：1.00）A.B.C.D.24.A 16-year-old
27、 student has been admitted to your psychiatric unit after fainting in physical education class. She has a diagnosis of anorexia nervosa, weighs 88 lb (40 kg), and is 54“ (1.6 m) tall. She has been weighing herself several times per day at home and has lost 30 lb (13.5 kg) in the past 3 months. Which
28、 nursing diagnosis would be most appropriate for the client? A. Disturbed thought processes. B. Impaired adjustment. C. Imbalanced nutrition. Less than body requirements. D. Ineffective sexuality patterns.（分数：1.00）A.B.C.D.25.A client is admitted for an overdose of amphetamines. When assessing this c
29、lient, the nurse should expect to have which of the following findings? A. Tension and irritability. B. Slow pulse. C. Hypotension. D. Constipation.（分数：1.00）A.B.C.D.26.When completing an assessment of a healthy adolescent client, which of the following would be most appropriate? A. Obtain a detailed
30、 account of the adolescents prenatal and early developmental history. B. Discuss sexual preferences and behaviors with the parents present for legal reasons. C. Discuss the clients smoking with parents present in the room. D. Assess the adolescent in private; gather additional information from the p
31、arents.（分数：1.00）A.B.C.D.27.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 inaccurate? A. Neonates. 10.6 to 16.5. B. 3 m
32、onths. 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.28.When assessing a toddler diagnosed with spastic cerebral palsy, which of the following would the nurse expect to find? A. Toe-walking. B. Drooling. C. Facial grimacing. D. Wide-based gait.（分数：1.00）A.B.C.D.29.
33、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. D. The clien
34、t verbalizes the importance of restricting fluids.（分数：1.00）A.B.C.D.30.A female neonate delivered by elective cesarean birth to a 25-year-old mother weighs 3,265g (7 lb, 3 oz). The nurse places the neonate under the warmer unit. In addition to routine assessments, the nurse should closely monitor thi
35、s neonate for which of the following? A. Temperature instability due to type of birth. B. Respiratory distress due to lack of contractions. C. Signs of acrocyanosis. D. Unstable blood sugars.（分数：1.00）A.B.C.D.二、BPart Two/B(总题数：20，分数：20.00)31.A young adult had a significant reaction to the Mantoux tes
36、t. What conclusion would the nurse make from the findings? A. The client has active tuberculosis. B. The client had active tuberculosis. C. The client has been exposed to tuberculosis. D. The client is immunocompromised.（分数：1.00）A.B.C.D.32.A child with type 1 diabetes mellitus develops diabetic keto
37、acidosis and receives a continuous insulin infusion. Which condition represents the greatest risk for this child? A. Hypercalcemia. B. Hyperphosphatemia. C. Hypokalemia. D. Hypernatremia.（分数：1.00）A.B.C.D.33.A few days after a colectomy, a client suddenly develops chest pain, shortness of breath, and
38、 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 typically A. is described as crushing and substernal. B. worsens with deep inspira
39、tion. C. is relieved with nitroglycerin. D. is relieved when the client leans forward.（分数：1.00）A.B.C.D.34.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
40、 further instruction? 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 teasp
41、oons of clear fluids after administering ipecac. “（分数：1.00）A.B.C.D.35.A nurse is reviewing prenatal care with a client. Which of the following statements by the client best expresses adequate understanding of nutritional needs during pregnancy? A. “I expect to gain a few pounds each month at first.
42、Then Ill really get big and put on 20 pounds or so. “ B. “I guess I will get big and gain 20 to 30 pounds and look pregnant.“ C. “Because I have to eat for two, I should eat whatever I want whenever I feel hungry. “ D. “I will need to eat more so that I will gain about 25 pounds, but I want to make
43、sure I dont fill up with junk food. “（分数：1.00）A.B.C.D.36.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.（
44、分数：1.00）A.B.C.D.37.A 2-year-old client returns from surgery after a bowel resection as a result of Hirschsprungs disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention takes priority? A. Changing the surgical dressing. B. Suctioning the nasopharynx frequently
45、to remove secretions. C. Irrigating the colostomy with 100 ml of normal saline solution. D. Auscultating lung sounds.（分数：1.00）A.B.C.D.38.Which of the following functions would the nurse expect to be unrelated to the placenta? A. Production of estrogen and progesterone. B. Detoxification of some drug
46、s and chemicals. C. Exchange site for food, gases, and waste. D. Production of maternal antibodies.（分数：1.00）A.B.C.D.39.The nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents? A. “The cast will b
47、e removed in 6 weeks. “ B. “A new cast is needed every 1 to 2 weeks. “ C. “A short leg cast is applied when the baby is ready to walk. “ D. “The cast will be removed when the baby begins to crawl. “（分数：1.00）A.B.C.D.40.The nurse is caring for a comatose client who has suffered a closed head injury. W
48、hat intervention should the nurse implement to prevent increases in intracranial pressure (ICP) ? A. Suction the airway every hour and as needed. B. Elevate the head of the bed 15 to 30 degrees. C. Turn the client and change his position every 2 hours. D. Maintain a well-lit room.（分数：1.00）A.B.C.D.41.The nurse is making a plan of care for the child with juvenile rheumatoid arthritis to reduce joint pain in the morning just after arising. Which of the following interventions would be included in the plan? A. Awakening the child once nightl
