试卷详情
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美国护士资格认证(CGFNS)-11
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[单项选择]Which of the following assessments indicates fetal distress()
A. Fetal scalp pH of 7.14.
B. Fetal heart rate (FHR) of 144 beats/minute.
C. Acceleration of FHR with contractions.
D. Long-term variability.
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[单项选择]A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client()
A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) test annually.
B. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
C. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.
D. The human papillomavirus (HPV), which causes condylomata aeuminata, can’t be transmitted during oral sex.
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[单项选择]When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should
A. position the client in a supine position.
B. elevate the head of the bed 90 degrees during meals.
C. encourage the client to remove dentures.
D. encourage thin liquids for dietary intake.
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[单项选择]The nurse is caring for a client who has hemoconcentration after fluid loss. Which IV fluids would be the most appropriate fluid replacement therapy for this client()
A. Distilled water.
B. Dextrose 5% in water (D5W) only.
C. DSW with 40 mEq of potassium chloride.
D. Dextrose 10% in saline.
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[单项选择]A male client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of severe pain in the surgical wound. Which action should the nurse take()
A. Assume he’s anxious about discharge, and administer pain medication.
B. Assess the surgical site and affected extremity.
C. Reassure the client that pain is a direct result of increased activity.
D. Suspect a wound infection, and monitor the client’s temperature and vital signs.
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[单项选择]The nurse is developing a care plan for a client in her 34th week of gestation who is experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor
A. Encouraging ambulation.
B. Serving a nutritious diet.
C. Promoting adequate hydration.
D. Performing nipple stimulation.
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[单项选择]Which client has the highest risk of ovarian cancer()
A. 30-year-old woman taking oral contraceptive pills.
B. 45-year-old woman who has never been pregnant.
C. 40-year-old woman with three children.
D. 36-year-old woman who had her first child at age 22.
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[单项选择]The nurse is planning care for a female client diagnosed with acute hepatitis A virus (HAV). What’s the primary mode of transmission for HAV()
A. Fecal contamination and oral ingestion.
B. Exposure to contaminated blood.
C. Sexual activity with an infected partner.
D. Sharing a contaminated needle or syringe.
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[单项选择]A client on an inpatient psychiatric unit at a community mental health center is pacing the hallway and appears agitated. When the nurse approaches him, he says loudly, "Leave me alone. " What’s the nurse’s best approach()
A. Say nothing and pace with the client.
B. Say "You sound upset. I’d like to help. "
C. Say "okay" and walk away.
D. Summon help in case the client becomes aggressive.
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[单项选择]A 16-year-old 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 5’4" (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 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.
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[单项选择]The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should()
A. use commercial preparations to remove corns.
B. cut toenails by rounding edges.
C. wash and inspect feet daily.
D. walk barefoot at least once each day.
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[单项选择]The nurse is delivering the client’s 10 AM medications. The client is away from his room for a diagnostic study. Which action is the most appropriate for the nurse to take()
A. Leave the medications on the client’s bedside table.
B. Ask the client’s roommate to keep the medications for the client until he returns.
C. Lock the medications in the medicine preparation area until the client returns.
D. Have the client skip that dose of medication.
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[单项选择]A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse’s priority would be to assess her()
A. neuromuscular function.
B. bowel sounds.
C. respiratory rate.
D. electrocardiogram (ECG) results.
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[单项选择]A mother brings her 5-month-old female child to the pediatric clinic. The child has had recurrent middle-ear infections since she was 3 months old. Which of the following areas is most important to assess()
A. How well the client eats.
B. The client’s weight gain since her last visit.
C. Whether the client received all of her prescribed antibiotic at the time of the last infection.
D. The client’s temperature.
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[单项选择]A 15-year-old primigravida gave birth 2 days ago. She tells the nurse that having her own little baby will be wonderful. Which nursing response would best evaluate the accuracy of the client’s expectations()
A. "Tell me what your day will be like after you take your baby home. "
B. "Will anyone be available to help you at home with the baby"
C. "Have you had any experience taking care of babies"
D. "What are you planning to do with your baby when you return to school"
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[单项选择]The nurse is assessing a 15-year-old female who is being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find()
A. Tachycardia.
B. Warm, flushed extremities.
C. Parotid gland tenderness.
D. Coarse hair growth.
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[单项选择]While evaluating the needs of a client during the second trimester, the nurse can anticipate which of the following()
A. Feelings of disbelief and ambivalence.
B. Feelings of clumsiness and "ugliness".
C. Increasing introspection but a general sense of well-being.
D. Anxiety about the labor and delivery experience.
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[单项选择]The nurse is giving instructions to a client who is going home with a cast on his leg. Which point is most critical()
A. Using crutches properly.
B. Exercising joints above and below the cast, as ordered.
C. Avoiding walking on a leg cast without the physician’s permission.
D. Reporting signs of impaired circulation.
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[单项选择]An elderly client with Alzheimer’s disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential for()
A. hypoglycemia.
B. fluid volume excess.
C. aspiration.
D. constipation.
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[单项选择]A nurse instructs a prenatal class about the importance of doing Kegel exercises frequently. Kegel exercises help to()
A. promote better breathing by strengthening the diaphragm muscle.
B. maintain good perineal muscle tone by tightening the pubococcygeus muscle.
C. minimize leg cramps by strengthening the calf muscles.
D. prepare the mother for pushing by strengthening the abdominal muscles.
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[单项选择]The nurse is planning care for a client after a tracheostomy. One of the client’s goals is to overcome verbal communication impairment. Which of the following interventions should the nurse include in the care plan()
A. Make an effort to read the client’s lips to foster communication.
B. Encourage the client’s communication attempts by allowing him time to select or write words.
C. Answer questions for the client to reduce his frustration.
D. Avoid using a tracheostomy plug because it blocks the airway.
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[单项选择]The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which of the following findings should the nurse consider abnormal()
A. More back pain than the first postoperative day.
B. Paresthesia in the dermatomes near the wounds.
C. Urinary retention or incontinence.
D. Temperature of 99.2°F(37.3℃).
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[单项选择]Which intervention will best help to prevent a client from falling()
A. Monitor the client regularly or continually if his condition warrants it.
B. Keep the bed at a level where the nurse can easily provide care.
C. Make sure the side rails of the client’s bed are down.
D. Restrain the client to prevent him from getting out of bed and falling.
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[单项选择]The nurse is caring for a client who is suicidal. When accompanying the client to the bathroom, the nurse should()
A. give him privacy in the bathroom.
B. allow him to shave.
C. open the window and allow him to get some fresh air.
D. observe him.
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[单项选择]The nurse is preparing a treatment plan for a client taking oral corticosteroids to control severe chronic asthma. Which statement indicates that the client understands his treatment plan()
A. "I should take corticosteroids on an empty stomach. "
B. "I need to take corticosteroids to help build up my immune system. "
C. "I should stop taking corticosteroids if I haven’t had an asthma attack for 1 week. "
D. "I’ll tell my other health care providers that I’m taking a corticosteroid. "
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[单项选择]The nurse is caring for a client undergoing IV antibiotic therapy with gentamicin sulfate. Which of the following interventions is most important()
A. Infuse the medication quickly to minimize its irritating effect on the walls of blood vessels.
B. Obtain renal function tests, such as blood urea nitrogen (BUN) and creatinine levels, throughout the course of therapy.
C. Assess for pulmonary and peripheral edema.
D. Obtain an order for an antiemetic to counteract the common adverse effect of nausea.
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[单项选择]During a routine follow-up examination, the nurse updates the client’s medication history. The client currently receives prednisone therapy. Concomitant use of an agent from which of the following classes could increase the risk of peptic ulcer disease()
A. Antidiabetic agents, administered orally.
B. Nonsteroidal anti-inflammatory drugs (NSAIDs).
C. Beta-adrenergic blockers.
D. Contraceptive agents, administered orally.
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[单项选择]A female client is being treated for genital herpes. The client should receive teaching on the
A. prevention of outbreaks of lesions.
B. need to abstain from sexual contact.
C. need to keep the perineal area moist.
D. need to wear tight-fitting nylon underwear.
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[单项选择]A nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for assistance. In reassessing the infant after I minute of CPR, the nurse finds that he still isn’t breathing and that he has no pulse. The nurse should then()
A. resume CPR beginning with breaths.
B. declare her efforts futile.
C. resume CPR beginning with chest compressions.
D. call for assistance.
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[单项选择]A 54-year-old female was found unconscious on the floor of her bathroom with self- inflicted wrist lacerations. An ambulance was called and the client was taken to the emergency department. When she was stable, the client was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Now that the client is feeling better, which nursing intervention is most appropriate()
A. Observing for extrapyramidal symptoms.
B. Beginning a therapeutic relationship.
C. Canceling any no-suicide contracts.
D. Continuing suicide precautions.
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[单项选择]The nurse is assessing a client diagnosed with appendicitis. Which of the following signs or symptoms should the nurse expect to find
A. Rigid abdomen, Levine’s sign, pain relief leaning forward.
B. Rebound tenderness, McBurney’s sign, low-grade fever.
C. Right lower quadrant pain, Chvostek’s sign, muscle guarding.
D. Periumbilical pain, Trousseau’s sign, pain relief with pressure.
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[单项选择]A family member is caring for a client diagnosed with Alzheimer’s disease. Which of the following is most likely to cause the caregiver depression and role strain()
A. The caregiver had a close relationship with the client before diagnosis of the illness.
B. The caregiver has no formal support, such as a visiting nurse or day care worker.
C. The caregiver understands the full reality of the disease and its inevitable progression.
D. The caregiver feels unable to control the client and unable to cope with caregiving.
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[单项选择]A client is to have a cesarean delivery because of continuous vaginal bleeding and an abnormal fetal heart rate tracing. Which of the following would be the best preoperative medication for this client()
A. Meperidine (Demerol).
B. Oxytocin (Pitocin).
C. Promethazine (Phenergan).
D. Glycopyrrolate (Robinul).
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[单项选择]The employer of a client on the psychiatric unit calls the nursing station inquiring about the client’s progress. The nurse doesn’t know if the client has given consent to allow the staff to give information out to callers on the phone. Which of the following would be the nurse’s best response()
A. "I’m not permitted to discuss her progress. "
B. "I’ll give you the name and telephone number of her physician. "
C. "I’ll have her call you. "
D. "I can’t confirm whether your employee is a client here. "
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[单项选择]The nurse is teaching a client about using vaginal medications. The nurse should instruct the client ()
A. use a tampon after insertion to increase medication absorption.
B. release and pull up on the applicator before removal.
C. never refrigerate suppositories.
D. use only a water-soluble lubricant when inserting a suppository.
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[单项选择]The nurse in the emergency department is assessing a 64-year-old client experiencing substernal chest pain. The client’s electrocardiogram shows evidence of myocardial ischemia. Which statement should indicate to the nurse that the client may be a candidate for thrombolytic therapy()
A. "I have had chest pain for 2 days. "
B. "My chest pain started 3 hours ago. "
C. "My chest pain stops when I take a nitroglycerin pill. "
D. "I have had chest pain on and off all week. "
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[单项选择]An 8-month-old boy is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of()
A. increased myelination.
B. intracranial hypotension.
C. cerebral hyperemia.
D. a slightly thicker cranium.
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[单项选择]The major goal of therapy in crisis intervention is to()
A. withdraw from the stress.
B. resolve the immediate problem.
C. decrease anxiety.
D. provide documentation of events.
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[单项选择]A 21-year-old primigravida has an emergency cesarean delivery under general anesthesia because of unanticipated fetal distress. One postoperative intervention is to assist her to turn every 2 hours. Which of the following conditions is this intervention intended to prevent
A. Pressure ulcers.
B. Muscular stiffness.
C. Respiratory complications.
D. Venous stasis.
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[单项选择]A 38-year-old client is hospitalized with obsessive-compulsive disorder. On admission, she becomes nervous and asks to go to the bathroom to brush her teeth. Her husband says that she brushes her teeth at least 25 times per day. The nurse notes that the client’s gums are inflamed and bleeding. What’s the best nursing intervention()
A. Have her stop brushing her teeth until the gums heal.
B. Allow her to continue her routine of daily brushing.
C. Monitor her dental care and set limits on the amount of daily brushing.
D. Brush her teeth for her.
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[单项选择]What is the normal pH range for arterial blood
A. 7.00 to 7.49.
B. 7.35 to 7.45.
C. 7.50 to 7.60.
D. 7.55 to 7.65.
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[单项选择]The nurse is teaching a client who has been prescribed allopurinol for the treatment of gout. Which instruction would the nurse give to the client()
A. Increase alcohol intake while taking the drug.
B. Avoid foods that are rich in purine.
C. Take aspirin for pain.
D. Take the drug between meals to promote absorption.
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[单项选择]A 4-year-old girl is admitted to the hospital to rule out leukemia. Which of the following would be the best room assignment()
A. With a 4-year-old girl who has rheumatoid arthritis.
B. With a 5-year-old boy who is having a tonsillectomy.
C. With a 4-year-old girl who has leukemia.
D. Alone in a private room.
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[单项选择]The nurse is caring for an elderly client who exhibits signs of dementia. The most common cause of dementia in an elderly client is()
A. delirium.
B. depression.
C. excessive drug use.
D. Alzheimer’s disease.
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[单项选择]The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get mammograms()
A. yearly after age 40.
B. after the birth of the first child and every 2 years thereafter.
C. after the first menstrual period and annually thereafter.
D. every 3 years between ages 20 and 40 and annually thereafter.
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[单项选择]The nurse provides fluid replacement for a client with burns on 35% of his body. It has been 12 hours since the burns occurred. His blood pressure is 85/60 mmHg. His pulse is 124 beats/minute. Urine output was 25 mL during the past hour. What orders should the nurse expect to receive from the physician()
A. Maintain IV fluids at the present rate, and continue to reassess vital signs and urine output hourly.
B. Increase the IV rate, and continue to reassess vital signs and urine output hourly.
C. Decrease the IV rate, and continue to reassess vital signs and urine output hourly.
D. Administer a vasoconstrictor, and reassess vital signs and urine output hourly.
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[单项选择]A multigravida in her 34th week of gestation presents in the emergency department complaining of vaginal bleeding. Which of the following should be the nurse’s first action()
A. Establish IV access.
B. Assess fetal heart rate (FHR) and maternal blood pressure.
C. Prepare the client for a cesarean delivery.
D. Assess maternal heart rate and respiratory rate.
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[单项选择]The nurse is caring for a client admitted to the hospital with a bowel obstruction. The nurse should wear sterile gloves when()
A. inserting an indwelling urinary catheter.
B. giving a back rub on intact skin.
C. changing an oxygen system.
D. inserting an IV catheter.
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[单项选择]The nurse is caring for a 45-year-old male client admitted with a retinal detachment in his left eye. What symptoms would the nurse expect to find during assessment
A. Flashing lights in the visual field.
B. Sudden eye pain.
C. Loss of color vision.
D. Colored halos around lights.
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[单项选择]The nurse is teaching a new group of mental health aides. The nurse should teach the aides that setting limits is most important for()
A. a depressed client.
B. a manic client.
C. a suicidal client.
D. an anxious client.
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[单项选择]The nurse teaches a mother how to provide adequate nutrition for her toddler, who has cerebral palsy. Which of the following observations indicates that teaching has been effective()
A. The toddler stays neat while eating.
B. The toddler finishes the meal within a specified period of time.
C. The child lies down to rest after eating.
D. The child eats finger foods by himself.
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[单项选择]Which procedure or practice is associated with surgical asepsis()
A. Hand washing.
B. Nasogastrie (NG) tube irrigation.
C. Colostomy irrigation.
D. IV catheter insertion.