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1、2021辽宁美国护士资格认证(CGFNS)考试考前冲刺卷本卷共分为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.When developing the postoperative plan of care for a child who is scheduled to have a tympanostomy tubes inserted into the right ear, which of the following interventions would the nurse identify
2、to accomplish the goal of facilitating drainageAApplying warm compresses to the right ear.BApplying a gauze dressing to the left ear.CApplying an ice pack to the left ear.DPositioning the child to lie on the right side. 2.A client with intrauterine growth retardation is admitted to the labor and del
3、ivery unit and started on an IV infusion of oxytocin (Pitocin). Which of the following is LEAST likely to be included in her plan of careAMonitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes.BAllowing the client to ambulate as tolerated.CHelping the client use bre
4、athing exercises to manage her contractions.DCarefully titrating the oxytocin based on her pattern of labor. 3.Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse shouldAkee
5、p the client warm.Bmaintain room temperature at 78F (25.6).Ckeep the client uncovered.Dmatch the room temperature with the clients body temperature. 4.Which of the following is not a contributing factor to unstable blood sugars in the neonateAPrematurity.BRespiratory distress.CPostdated infant.DCesa
6、rean delivery. 5.A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. What should the nurse do firstAAuscultate for bowel sounds.BPalpate the abdomen.CChange the clients position.DInsert a rectal tube. 6.A client is to be discharged from an acute care facili
7、ty after treatment of right leg thrombophlebitis. The nurse notes that the clients leg is pain free, without redness or edema. The nurses actions reflect which step in the nursing processAAssessment.BAnalysis.CImplementation.DEvaluation. 7.The nurse is instructing a client with angina about sublingu
8、al nitroglycerin. Which of the following points should be includedAThe shelf life of nitroglycerin is long, it keeps for up to 2 years.BStore the tablets in a tight, light-resistant container.CUse the tablets only when the pain is severe.DThe drug will cause increased urine output. 8.Otorrhea and rh
9、inorrhea are most commonly seen with which type of skull fractureABasilar.BTemporal.COccipital.DParietal. 9.Mr. Smith has had a cast applied to his arm as an outpatient in the emergency room. Which of the following home care instructions should the nurse advice for his cast careAUse a ruler to reach
10、 inside and scratch under the cast.BApply a heating pad to the arm for 24 hours after the injury.CUse powder on the skin around the cast.DSmell the cast for foul odors. 10.A multigravida at 36 weeks gestation visits the emergency department because her boyfriend has beaten her severely. What should
11、the nurse do firstAContact the authorities.BEnsure the clients safety.CIdentify a support person.DPhotograph the clients injuries. 11.Which of the following findings is suggestive of myocardial infarction (MI)ABelow-normal erythrocyte sedimentation rate.BElevated white blood cell count.CElevated ser
12、um cholesterol value.DElevated creatine phosphokinase (CPK) value. 12.Which one of the following observation would the nurse evaluate as an expected outcome for a client who has undergone surgical repair of an inguinal herniaAThe client will remain on a soft diet until the wound is healed.BThe clien
13、ts voiding patterns will return to normal within 6 months after surgery.CThe client will use a cane for assistance with ambulation for 2 to 6 weeks after surgery.DThe client will verbalize understanding of instructions to avoid lifting for 2 to 6 weeks 13.For a client with a head injury whose neck h
14、as been stabilized, the preferred bed position isATrendelenburgs.B30-degree head elevation.Cflat.Dside-lying. 14.The nurse is caring for a client who is experiencing auditory hallucinations. What would be most critical for the nurse to assessAPossible hearing impairment.BFamily history of psychosis.
15、CContent of the hallucinations.DPossible sella turcica tumors. 15.Which of the following signs or symptoms would lead the nurse to suspect that a 10-year-old child is experiencing early salicylate toxicityAChest pain.BPink-colored urine.CSlowed pulse rate.DDizziness. 16.Which of the following signs
16、and symptoms is classic for a patient with rheumatoid arthritisAJoint swelling, joint stiffness in the morning, and bilateral joint involvement.BCrepitus, development of Heberdens nodes, and anemia.CPain on weight-bearing, rash, and low-grade fever.DFatigue, leukopenia, and joint pain. 17.While cari
17、ng for the client with a burn injury, the nurse should observe for signs and symptoms of which complication believed to be due primarily to hypersecretion of gastric acidAParalytic ileus.BGastric distention.CHiatal hernia.DGastrointestinal ulceration. 18.A client with an incomplete small bowel obstr
18、uction is to be treated with a Cantor tube. Which of the following measures would most likely be included in the clients care once the Cantor tube has passed into the duodenumAMaintain bed rest with bathroom privileges.BAdvance the tube 2 to 4 inches at specified times.CProvide frequent mouth care.D
19、Provide ice chips for the client to suck. 19.In providing discharge teaching for the client after a modified radical mastectomy, the nurse should instruct the client that she might need to modify or avoid which of the following activitiesAShampooing her dog.BCaring for her tropical fish.CWorking in
20、her rose garden.DTaking a late-evening swim. 20.Which nursing diagnosis would the nurse anticipate as having the highest priority for the client with gestational diabetes in laborARisk for infection related to invasive procedures during labor.BRisk for injury to fetus related to the effects of diabe
21、tes on uteroplacental functioning.CDeficient knowledge related to lack of information about care during labor.DInterrupted family processes related to diabetes increasing the clients risk of complications. 21.When magnesium sulfate is administered to a client in labor, its action occurs at which of
22、the following sitesANeural-muscular junctions.BDistal renal tubules.CCentral nervous system (CNS).DMyocardial fibers. 22.To encourage adequate nutritional intake for a client with Alzheimers disease, what should the nurse doAStay with the client and encourage him to eat.BHelp the client fill out his
23、 menu.CGive the client privacy during meals.DFill out the menu for the client. 23.A client is having autonomic dysreflexia. What should the nurse do firstAPlace the client in Fowlers position.BSend a urine sample for culture.CAdminister nitroprusside sodium (Nipride) intravenously.DCall the physicia
24、n. 24.Eight hours after catheterization, the postoperative client with abdominal hysterectomy has not voided. The client tells the nurse, I dont think I can urinate. What should the nurse doACall and inform the surgeon of the clients status.BAdminister additional pain medication.CIncrease the client
25、s fluid intake.DAssess the clients bladder. 25.A child is to receive intrathecal methotrexate (Folex) for treatment of meningeal leukemia. For which reason would intrathecal administration be selectedAThe child has very poor veins and is unable to receive drugs IV.BThis drug would be destroyed by ga
26、stric acid and so it cant be given by mouth.CThis drug is poorly transported across the blood-brain barrier, so its administered intrathecally.DBecause the drug is rapidly absorbed if given IM, adverse effects may appear more quickly. 26.The nurse plans to teach a client who is receiving radiation t
27、herapy how to care for his skin at home. Which of the following should be included in the nurses instructionsAApply a heating pad to the area to relieve pain. BKeep the area covered when you go outdoors. CYou may use deodorant soap if you wish to cleanse the area. DPut baby oil on the area after eac
28、h treatment to keep it from getting dry. 27.A 15-year-old boy is admitted to the health care facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include which of the followingAViolence on television.BPassive parents.CAn internal l
29、ocus of control.DA single-parent family. 28.The nurse identifies a clients responses to actual or potential health problems during which step of the nursing processAAssessment.BAnalysis.CPlanning.DEvaluation. 29.The nurse notices that the clients pupils are fixed and dilated. What does this finding
30、indicateAThe client is permanently paralyzed.BThe client is going to be blind as a result of an injury.CThe client probably has meningitis.DThe client has received a significant brain injury. 30.During a panic attack, a client runs to the nurse and reports breathing difficulty, chest pains, and palp
31、itations. The client also is pale and has a wide open mouth and raised eyebrows. What should the nurse do firstAAssist with deep breathing into a paper bag.BOrient the client to person, place, and time.CSet limits for acting out delusional behaviors.DAdminister an anxiolytic agent IM. 31.A client un
32、dergoes a total laryngectomy and tracheostomy formation. On discharge, which instruction should the nurse give to the client and familyAClean the tracheostomy tube with alcohol and water. BFamily members should continue to talk to the client. COral intake of fluids should be limited for 1 week only.
33、 DLimit the amount of protein in the diet. 32.A client exhibits confusion and severe memory loss. At 11:30 AM, he tells the nurse that he is going to work and proceeds to walk toward the door. Which of the following actions should be the nurse takeARemind him that he retired from his job 10 years ag
34、o.BTell him that shell accompany him for a short walk outdoors.CDivert his attention toward the dining room where lunch is being served.DTell him that he does not have to go to work today. 33.A client is fully dilated. Which of the following actions would be inappropriate during the second stage of
35、laborAPositioning the mother for effective pushing.BPreparing for delivery of the baby.CAssessing for rupture of membranes.DAssessing vital signs every 15 minutes. 34.Emergency restraints or seclusion may be implemented without a physicians order under which of the following conditionsAWhen a writte
36、n order will be obtained from the primary physician within 1 hour.BIf a voluntary client wants to leave against medical advice.CWhen a minor child is out of control.DNever. 35.The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse in
37、clude in the teachingAMake inhalation longer than exhalation.BExhale through an open mouth.CUse diaphragmatic breathing.DUse chest breathing. 36.Which of the following would be most appropriate for the nurse to include in the plan of care for a dying child to meet the childs emotional needs during t
38、he last days of lifeARestrict visitors to the parents to avoid overtaxing the child.BAnswer the childs questions about illness and death honestly.CFocus on the childs physical needs to attempt to prevent sadness.DEncourage the child to play quietly with a roommate to provide pleasure. 37.The mother
39、of a child with flat feet asks the nurse why her child needs to wear corrective shoes. Which of the following is the most appropriate reason that the child needs to wear corrective shoesAPreventing the development of internal tibial torsion.BStrengthening the arches of the feet.CKeeping the legs in
40、proper alignment.DDelaying the development of femoral anteversion. 38.The nurse is caring for a child with leukemia. Which of the following should the nurse priority pay more attention toAPreventing injury.BMonitoring the childs platelet count.CMonitoring the childs temperature.DEncouraging increase
41、d fluid intake. 39.An 20-month-old with acquired immunodeficiency syndrome (AIDS) is seen in the clinic for health maintenance. Which of the following vaccines would the nurse anticipate administering to this toddlerADiphtheria-tetanus-acellular pertussis.BVaricella.CMeasles, mumps, and rubella.DHem
42、ophilus influenza. 40.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 instructionAI should flush my childs eye with room temperature tap water fo
43、r 15 to 20 minutes if a caustic material gets into it. BI should save the emesis if my child vomits. CI should call the poison control center if there are any symptoms. DI should give 2 to 5 teaspoons of clear fluids after administering ipecac. 41.Which of the following symptoms would indicate that
44、a client is at risk for autonomic dysreflexiaASudden, severe hypertension.BHot, dry skin.CParalytic ileus.DBradycardia. 42.A client is admitted to the emergency department with complaints of chest pain and shortness of breath. The nurses assessment reveals jugular vein distention. The nurse knows th
45、at when a client has jugular vein distention, its typically due toAa neck tumor.Ban electrolyte imbalance.Cdehydration.Dfluid overload. 43.A nurse is evaluating the effectiveness of dietary instructions in a client with diverticulitis. Regular consumption of which food would indicate that the client hasnt understood instructionsAFiber.BBananas.CCucumbers.DMilk products. 44.After gastric resection surgery, which of the following signs and symptoms would alert the nurse to the development of a leaki