QUESTIONS AND ANSWERS WITH RATIONALES
Which term describes the play activity of the preschool aged child? A.
Cooperative
B.Associative
C. Parallel
D. Solitary
B (Associative)
(Play of the preschool aged child is described as associative. At this stage, children are
more interested in playing with other children than they are with playing with toys.
The child may talkto other children and exchange toys or play games without any
rules. Answer A describes the play of a school-aged child. Answer C describes the play
of an infant.)
The nurse is ready to begin an exam on a nine-month-old infant who is sitting quietly
on hismother's lap. Which should the nurse do first?
A. Check the Babinski reflex
B. Listen to the heart and lung sounds
C. Palpate the abdomen
D. Check tympanic membranes
B (Listen to the heart and lung sounds)
(While the infant is quiet, the nurse should begin the exam by listening to the heart
and lungs. Ifthe nurse elicits the Babinski reflex , palpates the abdomen, or checks
the tympanic membranes,the infant may cry and it will be difficult to adequately
listen to the heart and lungs; therefore answers A,C, and D are incorrect.)
In terms of cognitive development, a three-year-old would be expected to:
A. Think abstractly
B. Use magical thinking
C. Understand conservation of matter
D. See things from the perspective of others
B (Use magical thinking)
,NGN NCLEX RN EXAM TEST BANK ACCURATE AND VERIFIED 600
QUESTIONS AND ANSWERS WITH RATIONALES
(A three-year-old is expected to use magical thinking, such as believing that a toy
bear is a real bear. Answers A, C, and D are incorrect because of abstract thinking,
conservation of matter, andthe ability to look at things from the perspective of others
are cognitive abilities of an older child)
Which of the following describes the language development of a two-year-old?
A. Doesn't understand yes and no
B. Understands the meaning of all words
C. Can combine three or four words
D. Repeatedly asks "why?"
C (can combine three or four words)
(The two year old can combine three to four words. Answers A and B are incorrect
because thetwo-year-old understands yes and no, but does not understand the
meaning of all the words.
Answer D is incorrect because seeking information and asking "why?" is typical of
the three-year old)
A client who has been receiving Urokinase (uPA) for deep vein thrombosis is noted to
have darkbrown urine in the urine collection bag. Which action should the nurse take
immediately?
A. Prepare an injection of vitamin K
B. Irrigate the urinary catheter with 50 mL of normal saline
C. Offer the client additional oral fluids
D. Withhold the medication and notify the physician
D (Withhold the medication and notify the physician)
(Urokinase is a thrombolytic agent used in the treatment of deep vein thrombosis,
pulmonary embolus, or myocardial infarction. The presence of dark brown or rust-
colored urine suggests bleeding. The nurse should withhold the medication, call the
doctor immediately, and prepare toadminister Amicar. Answer A is correct because
vitamin K is not the antidote for urokinase.
Answers B and C are incorrect because they do not address the adverse problem of
bleeding)
,Which of the following can occur with the frequent use of calcium based antacids?
A. Constipation
B. Hyperperistalsis
C. Delayed gastric emptying
D. Diarrhea
A (Constipation)
(The client taking calcium-based antacids will frequently develop constipation.
Answers B, C,and D are not associated with the use of calcium-based antacids;
therefore, they are incorrect.)
A client with a renal failure is prescribed a low potassium diet. Which food choice
would be bestfor this client?
A.1 cup beef broth
B.1 baked potato
C. 1/2 cup raisins
D.1 cup rice
D (1 cup of rice)
( Answer D is correct because one cup of rice is considered a low-potassium food.
The foods inanswer A, B, and C are incorrect because they contain higher amounts
of potassium)
An appropriate nursing intervention for the client with borderline personality disorder is:
A. Observing the client for signs of depression or suicidal thinking
B.Allowing the client to lead unit group sessions
C. Restricting the client's activity to the assigned unit of care throughout hospitalization D.
Allowing the client to select a primary caregiver
A (observing the client for signs of depression or suicidal thinking)
(Clients with borderline personality frequently suffer from depression and suicidal
thinking and should be assessed for risk of self-injury. Answers B and D are incorrect
choices because they allow the client too much control of the therapeutic environment.
Answer C is incorrect becausethe client's activities do not have to be restricted to the
unit after the level of depression has beendetermined )
, Which of the following is an expected finding in the assessment of a client with bulimia
nervosa
A. Extreme weight loss
B. Presence of lanugo over body
C. Erosion of tooth enamel
D. Muscle wasting
C (Erosion of tooth enamel)
(Erosion of tooth enamel caused by frequent self-induced vomiting is an expected
finding in aclient with bulimia nervosa. Answers A, B, and D are expected findings
in the client with anorexia nervosa; therefore, they are incorrect.)
Assuming that all have achieved normal cognitive and emotional development,
which of thefollowing children is at greatest risk for accidental poisoning?
A. One-year-old
B.Four-year-old
C. Eight-year-old
D. Twelve-year-old
B (Four-year-old)
(Because of their increased mobility, manual dexterity and curiosity, the four year old
is at greater risk for accidental poisoning. Other accidental injuries in this age group
include being struck by a car, falls, burns, and drowning. Answer A is incorrect
because the one-year-old lacksthe developmental skill to be at risk for accidental
poisoning. Answers C and D are incorrect because the eight-year-old and the twelve-
year-old are at less risk because they are aware of the dangers of accidental
poisoning)
Which statement made by the student nurse indicates the need for further teaching regarding
theadministration of heparin?
A."I will administer the medication 1-2 inches away from the umbilicus."
B."I will not massage the injection site after administering the heparin."
C."I will check the PTT before administering the heparin."
D."I will need to gently aspirate when I give the heparin."
D ("I will need to gently aspirate when I give the heparin.")
(The nurse should not aspirate when giving heparin; therefore, answer D indicates a
need for further teaching regarding heparin administration. Answers A, B, and C
indicate the student nurse understands the the correct administration of heparin and
are, therefore, incorrect answers.
)