Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
Author(s)Linda Anne Silvestri; Angela Silvestri
TEST BANK
1. Growth & Development — Milestones (Infant)
A 9-month-old infant is brought to the clinic. Which of the
following developmental behaviors is most appropriate for
this age?
A. Uses 2–3 words besides “mama/dada”
B. Sits steadily without support and pulls to stand; uses
pincer grasp
C. Rides a tricycle and uses scissors
D. Dresses independently and uses full sentences
Correct: B
Rationale:
B is correct — by about 9 months infants typically sit steadily,
may pull to stand, and begin to use a crude pincer grasp.
These are gross- and fine-motor milestones appropriate for
this age. Developmental expectations are age-specific and
guide safe assessment and anticipatory guidance.
,Why A is wrong: 2–3 words beyond “mama/dada” is more
typical of a toddler (around 15–24 months); at 9 months
receptive language and babbling are more typical.
Why C is wrong: Riding a tricycle and cutting with scissors are
preschool/early-school milestones (≈3–4 years).
Why D is wrong: Dressing independently and full sentences
develop later (~3–4 years).
2. Growth & Development — Separation Anxiety
A 2-year-old hospitalized child becomes very upset when the
parent leaves for an x-ray. Which nursing action supports
family-centered care and reduces separation anxiety?
A. Tell the child, “You’ll be fine — I’ll be here.”
B. Allow the parent to remain during the x-ray procedure if
hospital policy permits.
C. Give the child a sedative before the parent leaves.
D. Tell the parent to leave without saying goodbye to avoid
prolonged distress.
Correct: B
Rationale:
B is correct — family presence and support is central to
family-centered pediatric care and minimizes separation
anxiety; allowing the parent to accompany the child when
safe and allowed reduces distress and supports coping.
,Why A is wrong: Although well-intentioned, saying “I’ll be
here” may not be true for the nurse’s continuous presence
and can feel dismissive — honesty and offering realistic
support are better.
Why C is wrong: Giving a sedative solely to manage
separation anxiety is inappropriate; pharmacologic sedation
requires clinical indication and consent.
Why D is wrong: Encouraging the parent to leave without
saying goodbye increases mistrust and worsens separation
anxiety; brief, developmentally appropriate goodbyes are
recommended.
3. Respiratory — Croup (Acute Laryngotracheobronchitis)
A 3-year-old with inspiratory stridor, barky cough, and mild
retractions is brought to triage. Which initial nursing
intervention is most appropriate?
A. Administer high-flow oxygen by non-rebreather mask.
B. Encourage the child to sit on the caregiver’s lap and
provide cool mist or exposure to cool night air.
C. Begin chest physiotherapy immediately.
D. Prepare for immediate intubation without further
assessment.
Correct: B
Rationale:
B is correct — for mild to moderate viral croup, calming the
, child and providing humidity (cool mist or exposure to cool
air) while the caregiver holds the child reduces airway
irritation and anxiety. Positioning and keeping the child calm
are priority nursing actions.
Why A is wrong: High-flow oxygen by non-rebreather is
unnecessary for mild respiratory distress and may increase
agitation; oxygen is indicated if hypoxemia is present.
Why C is wrong: Chest physiotherapy is not effective for
upper airway obstruction like croup and may increase
distress.
Why D is wrong: Immediate intubation is reserved for severe
obstruction or respiratory failure; assess and escalate only as
clinically indicated.
4. Cardiac — Congenital Heart Defect (Tetralogy of Fallot)
A 2-month-old infant with Tetralogy of Fallot becomes
suddenly irritable, cyanotic, and lethargic while crying (a “Tet
spell”). What is the nurse’s best immediate action?
A. Place the infant in a knee-to-chest position (or draw knees
to chest), administer oxygen, and notify provider.
B. Perform rapid endotracheal intubation at bedside.
C. Administer a sedative to calm the infant.
D. Give a bolus of dextrose 10% IV.
Correct: A
Examination
9th Edition
Author(s)Linda Anne Silvestri; Angela Silvestri
TEST BANK
1. Growth & Development — Milestones (Infant)
A 9-month-old infant is brought to the clinic. Which of the
following developmental behaviors is most appropriate for
this age?
A. Uses 2–3 words besides “mama/dada”
B. Sits steadily without support and pulls to stand; uses
pincer grasp
C. Rides a tricycle and uses scissors
D. Dresses independently and uses full sentences
Correct: B
Rationale:
B is correct — by about 9 months infants typically sit steadily,
may pull to stand, and begin to use a crude pincer grasp.
These are gross- and fine-motor milestones appropriate for
this age. Developmental expectations are age-specific and
guide safe assessment and anticipatory guidance.
,Why A is wrong: 2–3 words beyond “mama/dada” is more
typical of a toddler (around 15–24 months); at 9 months
receptive language and babbling are more typical.
Why C is wrong: Riding a tricycle and cutting with scissors are
preschool/early-school milestones (≈3–4 years).
Why D is wrong: Dressing independently and full sentences
develop later (~3–4 years).
2. Growth & Development — Separation Anxiety
A 2-year-old hospitalized child becomes very upset when the
parent leaves for an x-ray. Which nursing action supports
family-centered care and reduces separation anxiety?
A. Tell the child, “You’ll be fine — I’ll be here.”
B. Allow the parent to remain during the x-ray procedure if
hospital policy permits.
C. Give the child a sedative before the parent leaves.
D. Tell the parent to leave without saying goodbye to avoid
prolonged distress.
Correct: B
Rationale:
B is correct — family presence and support is central to
family-centered pediatric care and minimizes separation
anxiety; allowing the parent to accompany the child when
safe and allowed reduces distress and supports coping.
,Why A is wrong: Although well-intentioned, saying “I’ll be
here” may not be true for the nurse’s continuous presence
and can feel dismissive — honesty and offering realistic
support are better.
Why C is wrong: Giving a sedative solely to manage
separation anxiety is inappropriate; pharmacologic sedation
requires clinical indication and consent.
Why D is wrong: Encouraging the parent to leave without
saying goodbye increases mistrust and worsens separation
anxiety; brief, developmentally appropriate goodbyes are
recommended.
3. Respiratory — Croup (Acute Laryngotracheobronchitis)
A 3-year-old with inspiratory stridor, barky cough, and mild
retractions is brought to triage. Which initial nursing
intervention is most appropriate?
A. Administer high-flow oxygen by non-rebreather mask.
B. Encourage the child to sit on the caregiver’s lap and
provide cool mist or exposure to cool night air.
C. Begin chest physiotherapy immediately.
D. Prepare for immediate intubation without further
assessment.
Correct: B
Rationale:
B is correct — for mild to moderate viral croup, calming the
, child and providing humidity (cool mist or exposure to cool
air) while the caregiver holds the child reduces airway
irritation and anxiety. Positioning and keeping the child calm
are priority nursing actions.
Why A is wrong: High-flow oxygen by non-rebreather is
unnecessary for mild respiratory distress and may increase
agitation; oxygen is indicated if hypoxemia is present.
Why C is wrong: Chest physiotherapy is not effective for
upper airway obstruction like croup and may increase
distress.
Why D is wrong: Immediate intubation is reserved for severe
obstruction or respiratory failure; assess and escalate only as
clinically indicated.
4. Cardiac — Congenital Heart Defect (Tetralogy of Fallot)
A 2-month-old infant with Tetralogy of Fallot becomes
suddenly irritable, cyanotic, and lethargic while crying (a “Tet
spell”). What is the nurse’s best immediate action?
A. Place the infant in a knee-to-chest position (or draw knees
to chest), administer oxygen, and notify provider.
B. Perform rapid endotracheal intubation at bedside.
C. Administer a sedative to calm the infant.
D. Give a bolus of dextrose 10% IV.
Correct: A
