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1、2022年陕西美国护士资格认证(CGFNS)考试真题卷（3）本卷共分为1大题50小题，作答时间为180分钟，总分100分，60分及格。一、单项选择题（共50题，每题2分。每题的备选项中，只有一个最符合题意） 1.What is the most appropriate nursing diagnosis for the client with acute pancreatitisADeficient fluid volume.BExcess fluid volume.CDecreased cardiac output.DIneffective gastrointestinal tissue p
2、erfusion. 2.After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of Parental role conflict related to childs hospitalization. Which defining characteristic would most suggest this diagnosisASupportive child-parent interaction (speaking, listening, touching, and ey
3、e-to-eye contact).BParents active participation in childs physical or emotional care.CParents failure to use available support systems or agencies to assist in coping.DEvidence of adaptation to parental role changes. 3.When caring for a client who is having her second baby, the nurse can anticipate
4、the clients labor will be which of the followingAShorter than her first labor.BAbout half as long as her first labor.CAbout the same length of time as her first labor.DA length of time that cant be determined based on her first labor. 4.The nurse is caring for a primigravida who is scheduled for a f
5、etal acoustic stimulation test (FAST). The nurse should explain to the client that the primary purpose of this test is toAinduce contractions.Binduce fetal heart rate accelerations.Cshorten the contraction stress test.Ddetermine fluid volume. 5.The nurse is caring for a client whom she suspects is p
6、aranoid. How would the nurse confirm this assessmentAIndirect questioning.BDirect questioning.CLead-in sentences.DOpen-ended sentences. 6.A client refuses his evening dose of haloperidol (Haldol) then becomes extremely agitated in the day room while other clients are watching television. He begins c
7、ursing and throwing furniture. The nurses first action is toAcheck the clients medical record for an order for an IM as needed dose of medication for agitation.Bplace the client in full leather restraints.Ccall the physician and report the behavior.Dremove all other clients from the day room. 7.A cl
8、ient is admitted to the hospital with a productive cough, night sweats, and a fever. Which action is most important in the initial plan of careAAssessing the clients temperature every 8 hours.BPlacing the client in respiratory isolation.CMonitoring the clients fluid intake and output.DWearing gloves
9、 during all client contact. 8.Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for which conditionAHypocortisolism.BHypoglycemia.CHyperglycemia.DHypercalcemia. 9.Which nursing intervention would most likely lead to a hyposmolar stateAPerforming nasogastric (NG
10、) tube irrigation with normal saline solution.BWeighing the client daily.CAdministering tap water enema until the return is clear.DEncouraging the client with excessive perspiration to drink broth. 10.Which of the following would be the best approach when trying to take a crying toddlers temperature
11、AIgnore the crying and screaming.BEncourage the mother to hold the child.CTalk to the mother first and then to the toddler.DBring extra help so it can be done quickly. 11.The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose le
12、vel of 160 mg/dL. The nurse should anticipate that the client will need toAstart using insulin.Bstart taking an oral antidiabetic drug.Cmonitor her urine for glucose.Dbe taught about diet. 12.Which of these signs suggests that a client with syndrome of inappropriate antidiuretic hormone (SIADH) secr
13、etion has developed complicationsATetanic contractions.BNeck vein distention.CWeight loss.DPolyuria. 13.In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. The nurses best response would be,AWill you briefly summarize your poin
14、t because others need time alsoBYour behavior is obnoxious and drains the group. CTo ignore the behavior and allow him to vent.DIm so frustrated with your behavior. 14.The nurse notices that a client with obsessive-compulsive disorder washes his hands for long periods each day. How should the nurse
15、respond to this compulsive behaviorABy designating times during which the client can focus on the behavior.BBy urging the client to reduce the frequency of the behavior as rapidly as possible.CBy calling attention to or attempting to prevent the behavior.DBy discouraging the client from verbalizing
16、anxieties. 15.The nurse is interviewing a client about his medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancerADuodenal ulcers.BHemorrhoids.CWeight gain.DPolyps. 16.Lochia normally progresses in which patternARubra, serosa, alba.BSerosa, rub
17、ra, alba.CSerosa, alba, rubra.DRubra, alba, serosa. 17.A client who is 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping her cope with these crampsASuggesting that she walk for 1 hour twice per day.BAdvising her to take over-the-counter cal
18、cium supplements twice per day.CTeaching her to dorsiflex her foot during the cramp.DInstructing her to increase milk and cheese intake to 8 to 10 servings per day. 18.A term neonates mother is O-negative, and cord studies indicate that the neonate is A-positive. Which of the following would be leas
19、t likely if the neonate developed neonate hemolytic diseaseALethargy or irritability.BPoor feeding patterns including vomiting.CWeight loss greater than 10%.DSigns of kernicterus. 19.The nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can
20、Aprepare the child by positive self-talk.Bestablish a time limit to get ready for the procedure.Chold and rock him and give him a security object.Dcount and sing with the child. 20.A 15-year-old female with a urinary tract infection is admitted to the facility. She tells the nurse she hopes shes pre
21、gnant. Which of the following would be the best response by the nurseADoes your mother know about thisBTell me what pregnancy would mean to you. CCongratulations. Does the babys father knowDI hope you arent pregnant; youre too young. 21.A client with a diagnosis of a bleeding gastric ulcer goes to t
22、he operating room for a partial gastrectomy. Postoperative nursing care would includeAadministering pain medications every 6 hours.Bwithholding fluids by mouth until the return of peristalsis.Cpositioning the client in high Fowler position.Dflushing the nasogastric (NG) tube with sterile water. 22.W
23、hich of the following would be least likely to indicate anticipated bonding behaviors by new parentsAThe parents willingness to touch and hold the neonate.BThe parents expression of interest about the size of the neonate.CThe parents indication that they want to see the neonate.DThe parents interact
24、ions with each other. 23.A client who is breast-feeding has a temperature of 102F (38.9) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which of the following actions would be inappropriate in managing the clients breast engorgementAApplying frozen cabbage leave
25、s to the breasts.BEncouraging the client to shower with her back to the water.CEncouraging the client to nurse her baby frequently.DApplying a breast binder to support the breasts. 24.A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous fistula was created in his left
26、 arm for hemodialysis. When preparing the client for discharge, the nurse should reinforce which dietary instructionABe sure to eat meat at every meal. BMonitor your fruit intake and eat plenty of bananas. CRestrict your salt intake. DDrink plenty of fluids. 25.The least serious form of brain trauma
27、, characterized by a brief loss of consciousness and period of confusion, is calledAcontusion.Bconcussion.Ccoup.Dcontrecoup. 26.During her first prenatal visit, a client expresses concern about gaining weight. Which of the following would be the nurses best actionAAsk the client how she feels about
28、gaining weight and provide instructions about expected weight gain and diet.BBe alert for a possible eating problem and do a further in-depth assessment.CReport the clients concerns to her caregiver.DAsk her to come back to the clinic every 2 weeks for a weight check. 27.The physician orders a tricy
29、clic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the past 6 months. The nurse should take which of the following actionsAAdminister the medication as ordered.BDiscontinue the medication.CQuestion the order with the physician.DInform the client that he shou
30、ld discuss the MI with the physician. 28.A client has been diagnosed with type A hepatitis. What special precautions should the nurse take when caring for this clientAPut on a mask and gown before entering the clients room.BWear gloves and a gown when removing the clients bedpan.CPrevent the droplet
31、 spread of the organism.DUse caution when bringing food to the client. 29.A 9-month-old infant is admitted with diarrhea and deficient fluid volume. The nurse plans to assess this clients vital signs frequently. What other action would provide the most important assessment informationAMeasuring the
32、infants body weight.BObtaining a stool specimen for analysis.CObtaining a urine specimen for analysis.DInspecting the infants posterior fontanel. 30.A clients chest X-ray reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results fromAcardiogenic pulmo
33、nary edema.Brespiratory alkalosis.Cincreased pulmonary capillary permeability.Drenal failure. 31.When developing a plan of care for a toddler with a seizure disorder, which of the following would be inappropriateAPadded side rails.BOxygen mask and bag system at bedside.CArm restraints while asleep.D
34、Cardiopulmonary monitoring. 32.When administering gentamicin to a preschooler, which of the following monitoring schedules is best for determining the drugs effectivenessAA serum trough level every morning.BA serum peak level after the second dose.CA serum trough and peak level around the third dose
35、.DSerial serum trough levels after three doses (24 hours). 33.The nurse is assessing the puncture site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluationA15-mm induration.BReddened area.C10-mm bruise.DBlister. 34.When assessing a cl
36、ient with chest pain, the nurse obtains a thorough history. Which statement by the client is most suggestive of angina pectorisAThe pain lasted for about 45 minutes. BThe pain resolved after I ate a sandwich. CThe pain worsened when I took a deep breath. DThe pain occurred while I was mowing the law
37、n. 35.A 3-month-old infant just had a cleft lip and palate repair. To prevent trauma to the operative site, the nurse should do which of the followingAGive the baby a pacifier to help soothe him.BLie the baby in the prone position.CPlace the infants arms in soft elbow restraints.DAvoid touching the
38、suture line, even to clean. 36.To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instructionsALie down after meals to promote digestion.BAvoid coffee and alcoholic beverages.CTake antacids before meals.DLimit fluids with meals. 37.A client un
39、dergoes a total hip replacement. Which statement made by the client would indicate to the nurse that the client requires further teachingAIll need to keep several pillows between my legs at night. BI need to remember not to cross my legs. Its such a habit. CThe occupational therapist is showing me h
40、ow to use a sock puller to help me get dressed. DI dont know if Ill be able to get off that low toilet seat at home by myself. 38.Which behavior would cause the nurse to suspect that a clients labor is moving quickly and that the physician should be notifiedAAn increased sense of rectal pressure.BA
41、decrease in intensity of contractions.CAn increase in fetal heart rate variability.DEpisodes of nausea and vomiting. 39.When assessing an infant for changes in intracranial pressure (ICP), its important to palpate the fontanels. Where the nurse should palpate to assess the anterior fontanelAABBCCDD
42、40.A 10-year-old diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which of the following is a part of the childs careATaking vital signs every 4 hours and obtaining daily weight.BObtaining a blood sample for electrolyte analysis every morning.CC
43、hecking every urine specimen for protein and specific gravity.DEnsuring that the child has accurate intake and output and eats a high-protein diet. 41.The nurse reinforces the physicians description of a fasciotomy for a client. When a fasciotomy is performed to alleviate compartment syndrome, the f
44、ascia is opened along the length of the muscle compartment andAthe skin is sutured loosely.Ba pressure dressing is applied.Cthe skin is left open.Da skin graft is placed. 42.Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the followingAMuscle weakness.
45、BTremors.CDiaphoresis.DConstipation. 43.Which of the following describes how the nurse interprets a neonates Apgar score of 8 at 5 minutesAA neonate who is in good condition.BA neonate who is mildly depressed.CA neonate who is moderately depressed.DA neonate who needs additional oxygen to improve the Apgar score. 44.Which of the following describes the rationale for administering vitamin K to every neonateANeonates dont receive the clotting factor in utero.BThe neonat