2021陕西美国护士资格认证(CGFNS)考试考前冲刺卷.docx

2021陕西美国护士资格认证(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.Which of the following is the single most reliable indicator of the existence and intensity of acute painA. The clients vital signs.B. The clients self-report of pain.C. The nurses assessment of the client.D. The severity of the condition causing the pain. 2.When helping the client who has had a cerebrovascular accident (CVA) learn self-care skills, the nurse should use which of the following interventions to help him learn to dress himselfA. 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 to ask his wife for help when dressin 3.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 assessments would be the priorityA. Maternal urinary output.B. Fetal position.C. Fetal heart rate variability.D. Maternal respiratory rat 4.A client is taking chlorpropamide (Diabenese). Which of the following side effects should be nurse expect from the medicationA. Hypoglycemia.B. Oral candidiasis.C. Dumping syndrome.D. Extrapyramidal symptoms. 5.A client is at risk for developing a pressure ulcer. The first warning of an impending pressure ulcer is when pressure applied to skin it turnsA. whitish.B. yellowish.C. bluish.D. reddis 6.A client has had a total gastrectomy for gastric cancer. Which one of the following is the most appropriate expected outcomes about nutritionA. The client will learn to self-administer enteral feedings every 4 hours.B. The client will maintain adequate nutrition through oral or parenteral feedings.C. The client will regain any weight lost within 4 weeks of the surgical procedure.D. The client will eat three full meals a day without experiencing gastric complications. 7.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 determines that the client is most likely experiencing which of the following types of abortionA. Complete.B. Threatened.C. Inevitable.D. Misse 8.The nurse would plan to use an abduction pillow (or splint) after a total hip replacement. What is the purpose for this activityA. To prevent hip flexion.B. To prevent dislocation of the prosthesis.C. To increase peripheral circulation.D. To decrease formation of sacral pressure ulcers. 9.A preschool-aged child who is hospitalized with gastroenteritis has been NPO. The physician has written an order to advance the diet as tolerated. Which of the following food is the most appropriate for the first feeding the nurse should offer the childA. Clear lemon carbonated beverage.B. Toast.C. Cooked cereal.D. Ice cream shak 10.Mrs. Brown, who is breast-feeding, asks the nurse if she should supplement breast- feeding with formula feeding. The nurse bases the response on which of the followingA. Formula feeding should be avoided to prevent interfering with the breast milk supply.B. Primarily, water supplements should be used to prevent jaundice.C. Formula supplements can provide nutrients not found in breast milk.D. More vigorous sucking is needed for a bottle-feeding, so supplements should be avoide 11.Emergency restraints or seclusion may be implemented without a physicians order under which of the following conditionsA. When a written order will be obtained from the primary physician within 1 hour.B. If a voluntary client wants to leave against medical advice.C. When a minor child is out of control.D. Never. 12.Which of the following findings is suggestive of myocardial infarction (MI)A. Below-normal erythrocyte sedimentation rate.B. Elevated white blood cell count.C. Elevated serum cholesterol value.D. Elevated creatine phosphokinase (CPK) valu 13.The physician prescribes clomiphene citrate (Clomid) for a woman who has been having difficulty getting pregnant. When preparing the teaching plan for the client about this drugs potential side effects, which of the following would the nurse include in the teaching planA. Increase in fibrocystic breast disease.B. Increase in congenital anomalies.C. Multiple pregnancies.D. Increase in spontaneous abortions. 14.The head nurse is observing a new graduate nurse instill eye drops into a clients eyes. The head nurse evaluates that the new graduate is using appropriate technique when which of the following steps is incorporated into the procedureA. The client is instructed to apply pressure to the eyes after instillation of the eye drops.B. The nurses hand is stabilized on the clients forehead while instilling the drops.C. The medication is placed onto the clients sclera.D. The client is instructed to look at the nurse while the drops are being instille 15.While a client with hypertension is being assessed, he says to the nurse, "I really dont know why Im here. I feel fine and havent had any symptoms. " Which of the following would be the nurses best responseA. "Symptoms of hypertension are often not present. "B. "Symptoms of hypertension signify a high risk of stroke. "C. "Symptoms of hypertension occur only with malignant hypertension. "D. "Symptoms of hypertension appear after irreversible kidney damage has occurred. " 16.A client with heart failure loses 3.2 kg while hospitalized. Approximately how many pounds has the client lostA. 1 pound.B. 3 pounds.C. 5 pounds.D. 7 pounds. 17.The client is taking carbamazepine (Tegretol) to treat his trigeminal neuralgia. While preparing the clients teaching plan, which of the following instructions should the nurse includeA. Limit physical activity while taking the drug.B. Eliminate caffeine from the diet while taking drug.C. Arrange to have a CBC drawn weekly.D. Take the drug on an empty stomac18.A client who has stress incontinence has been given a pamphlet that describes Kegel exercises. Which of the following statements indicates that the client has understood the instructions in the pamphletA. "It will probably take a year before the exercises are effective. "B. "I should perform these exercises every evening. "C. "I can do these exercises sitting up, lying down, or standing. "D. "I need to tighten my abdominal muscles to do these exercises correctly. " 19.Which of the following is of the nurses the primary concern for a client after cataract removal surgeryA. The client states her vision is clear.B. The client states her infection is under control.C. The client states she is able to administer parenteral pain medication.D. The client describes methods to prevent an increase in intraocular pressur 20.The nurse noticed that an 8-month-old childs posterior fontanel is slightly open. Which of the following should the nurse do nextA. Check the childs head circumference.B. Question the mother about the childs delivery.C. Schedule an X-ray of the childs head.D. Document this as a normal findin 21.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 10 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 womanA. Her long-term use of estrogen.B. Her weight.C. Her family.D. Her rac 22.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 careA. Use a ruler to reach inside and scratch under the cast.B. Apply a heating pad to the arm for 24 hours after the injury.C. Use powder on the skin around the cast.D. Smell the cast for foul odors. 23.A client is prescribed 1000 mL of an antibiotic solution to be given over 6 hours. What would be the flow rate The infusion set administers 15 gtts/mL.A. 28 gtts/min.B. 35 gtts/min.C. 42 gtts/min.D. 45 gtts/min. 24.A client asks the nurse to help her make out her will. In this situation, what should be the nurses best responseA. "I dont believe in getting involved in legal matters, but maybe I can find another nurse wholl help you. "B. "You need to consult an attorney because Im not trained in such matters. Is there a family lawyer I can call for you"C. "Im not a lawyer, but Ill do what I can for you. "D. "You have a long way to go before youll need to do that. Lets wait on it a while, shall we" 25.During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. Which of the following explains his actionA. Somatic delusions.B. Waxy flexibility.C. Neologisms.D. Nihilistic delusions. 26.The nurse would evaluate that the client understands his home care instructions after scleral buckling for a detached retina if the client says which of the following statementsA. "I should avoid abrupt movements of the head. "B. "I should exercise the eye muscles each day. "C. "I should turn the entire head rather than just the eyes for sight. "D. "I should avoid activities requiring good depth perception. " 27.A primipara is under nursing care during the first hour after a vaginal delivery of a viable neonate under lumbar epidural anesthesia and intravenous fluids. The client has a pulse rate of 65 bpm, temperature of 99.9°F (37.7), fundus firm at one finger breath above the midline, and a slow trickle of dark red vaginal bleeding on the perineal pad. The clients legs are still somewhat numb. What should the nurse doA. Discontinue the clients intravenous fluids if the client is drinking fluids.B. Notify the anesthesiologist who performed the lumbar epidural anesthesia.C. Massage the fundus and contact the clients physician immediately.D. Continue to monitor the clients temperature on an hourly basis. 28.A priority nursing diagnosis during the first 24 hours following an MI isA. Ineffective cardiac tissue perfusion.B. Risk for infection.C. Deficient fluid volume.D. Constipation. 29.A pregnant client who is diabetic is at risk for having a large-for-gestational-age infant because of which of the followingA. Excess sugar causing 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 functionin 30.The nurse is caring for several clients who have eating disorders. Based on appearance, how would the nurse distinguish bulimic clients from anorectic clientsA. By their teeth.B. By body size and weight.C. By looking for Mallory-Weiss tears.D. The clients are indistinguishable upon physical examination. 31.The nurse is assessing a 15-year-old female who is being admitted for treatment of anorexia nervosa. Which of the following clinical manifestation is the nurse most likely to find from the clientA. Tachycardia.B. Coarse hair growth.C. Parotid gland tenderness.D. Warm, flushed extremities.32.A client with a seizure disorder has been prescribed phenytoin (Dilantin). Which of the following should the nurse include in the teaching planA. It will be necessary for the client to take potassium supplements to prevent hypokalemia.B. The client should use a soft toothbrush and floss teeth daily.C. The use of phenytoin can lead to the development of diabetes.D. It is appropriate to substitute various brands of phenytoin as long as the dosage is the sam 33.The nurse at a substance abuse center answers the phone. A probation officer asks if a client is in treatment. The nurse responds, "No, the client youre looking for isnt here. " Which of the following statements best describes the nurses responseA. Correct because she didnt give out information about the client.B. A breech of the principle of veracity because the nurse is misleading the officer.C. Illegal because shes withholding information from law enforcement agents.D. A violation of confidentiality because she informed the officer that the client wasnt ther 34.A client with diverticulitis is treated as an outpatient with drug therapy. Which of the following medication would most probably be included in the drug therapyA. Broad-spectrum antibiotics.B. Opioid analgesics.C. Tranquilizers.D. Laxatives. 35.The nurse is caring for a child with leukemia. Which of the following should the nurse priority pay more attention toA. Preventing injury.B. Monitoring the childs platelet count.C. Monitoring the childs temperature.D. Encouraging increased fluid intak36.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 saysA. "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 activities, 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. " 37.A multigravida at 37 weeks gestation tells the nurse that she has frequent heartburn. The nurse teaches the client with suggestions for obtaining relief from the heartburn. Which of the following statements by the patient indicates that she has understood the nurses instructionsA. "I can take a teaspoon of baking soda in water occasionally. "B. "I should eat only three large meals and drink plenty of fluids. "C. "Its all right for me to have a fried hamburger and fries. "D. "I should eat smaller, more frequent meals with fluids. " 38.A client is having autonomic dysreflexia. What should the nurse do firstA. Place the cli