Saunders Comprehensive Review for the NCLEX-PN®
Examination
9th Edition
Author(s)Linda Anne Silvestri; Angela Silvestri
TEST BANK
1
A 9-month-old infant is brought to the clinic for well-baby
care. Which milestone should the nurse expect the infant to
demonstrate?
A. Uses a spoon to feed self independently.
B. Pulls to stand and may cruise along furniture.
C. Speaks in three-word sentences.
D. Skips when walking.
Correct answer: B
Rationale:
• B (Correct): At about 9 months infants commonly pull to
stand and begin cruising. This reflects appropriate gross
motor development for this age.
,• A (Incorrect): Independent spoon use usually appears later
(around 15–18 months); at 9 months the infant may grasp
a spoon but won't use it skillfully.
• C (Incorrect): Three-word sentences are a
toddler/language milestone typically seen around 2–3
years.
• D (Incorrect): Skipping is a higher-level gross motor skill
seen in preschool/early school age (≈4–6 years).
Developmental principle: Assess milestones in expected
age ranges and use them to identify delays early for
referral.
2
A toddler with acute otitis media is irritable and refuses to
eat. The nurse recognizes that the most appropriate initial
action to relieve ear pain is to:
A. Administer the prescribed acetaminophen per weight.
B. Place warm compresses over the ear.
C. Apply a topical anesthetic ear drop.
D. Offer ice chips.
Correct answer: A
Rationale:
• A (Correct): Systemic analgesia (weight-based
acetaminophen or ibuprofen) is first-line for pediatric ear
, pain and addresses fever and pain safely. Always verify
weight and dose.
• B (Incorrect): Warm compresses may provide comfort but
are adjunctive; they are not the most effective initial
measure compared with systemic analgesia.
• C (Incorrect): Topical anesthetic ear drops are not routinely
recommended for otitis media and may be contraindicated
if tympanic membrane rupture is suspected.
• D (Incorrect): Ice chips are not appropriate for ear pain
and may increase refusal to eat; cold may provide minimal
relief but is not first choice.
Safety principle: Give age/weight-appropriate analgesics
and confirm dosing calculations before administration.
3
A 4-year-old child with asthma is brought to the ED in
respiratory distress. Which action should the nurse perform
first?
A. Administer a quick-acting bronchodilator via nebulizer.
B. Obtain a chest x-ray.
C. Start an IV for medications.
D. Auscultate the lungs to document baseline.
Correct answer: A
Rationale:
, • A (Correct): In acute asthma exacerbation, relieving
bronchospasm (airway/breathing priority) with a quick-
acting bronchodilator (albuterol) is the immediate priority.
This aligns with ABCs.
• B (Incorrect): Chest x-ray may be useful later but is not
emergent and should not delay bronchodilator therapy.
• C (Incorrect): IV access may be needed but is secondary to
immediate bronchodilator delivery, which can often be
given via nebulizer or MDI with spacer.
• D (Incorrect): Auscultation is part of assessment but does
not treat the life-threatening bronchospasm; do not delay
treatment to perform only assessment.
Clinical principle: Prioritize airway/breathing
interventions; treat first, then investigate.
4
A school-age child is diagnosed with type 1 diabetes mellitus.
When teaching the family about insulin administration, the
nurse should emphasize:
A. Use the dorsogluteal site for consistent absorption.
B. Rotate injection sites within the same anatomical region.
C. Store all insulin vials in the freezer when not in use.
D. Always draw multiple insulins into the syringe in any order.
Correct answer: B
Examination
9th Edition
Author(s)Linda Anne Silvestri; Angela Silvestri
TEST BANK
1
A 9-month-old infant is brought to the clinic for well-baby
care. Which milestone should the nurse expect the infant to
demonstrate?
A. Uses a spoon to feed self independently.
B. Pulls to stand and may cruise along furniture.
C. Speaks in three-word sentences.
D. Skips when walking.
Correct answer: B
Rationale:
• B (Correct): At about 9 months infants commonly pull to
stand and begin cruising. This reflects appropriate gross
motor development for this age.
,• A (Incorrect): Independent spoon use usually appears later
(around 15–18 months); at 9 months the infant may grasp
a spoon but won't use it skillfully.
• C (Incorrect): Three-word sentences are a
toddler/language milestone typically seen around 2–3
years.
• D (Incorrect): Skipping is a higher-level gross motor skill
seen in preschool/early school age (≈4–6 years).
Developmental principle: Assess milestones in expected
age ranges and use them to identify delays early for
referral.
2
A toddler with acute otitis media is irritable and refuses to
eat. The nurse recognizes that the most appropriate initial
action to relieve ear pain is to:
A. Administer the prescribed acetaminophen per weight.
B. Place warm compresses over the ear.
C. Apply a topical anesthetic ear drop.
D. Offer ice chips.
Correct answer: A
Rationale:
• A (Correct): Systemic analgesia (weight-based
acetaminophen or ibuprofen) is first-line for pediatric ear
, pain and addresses fever and pain safely. Always verify
weight and dose.
• B (Incorrect): Warm compresses may provide comfort but
are adjunctive; they are not the most effective initial
measure compared with systemic analgesia.
• C (Incorrect): Topical anesthetic ear drops are not routinely
recommended for otitis media and may be contraindicated
if tympanic membrane rupture is suspected.
• D (Incorrect): Ice chips are not appropriate for ear pain
and may increase refusal to eat; cold may provide minimal
relief but is not first choice.
Safety principle: Give age/weight-appropriate analgesics
and confirm dosing calculations before administration.
3
A 4-year-old child with asthma is brought to the ED in
respiratory distress. Which action should the nurse perform
first?
A. Administer a quick-acting bronchodilator via nebulizer.
B. Obtain a chest x-ray.
C. Start an IV for medications.
D. Auscultate the lungs to document baseline.
Correct answer: A
Rationale:
, • A (Correct): In acute asthma exacerbation, relieving
bronchospasm (airway/breathing priority) with a quick-
acting bronchodilator (albuterol) is the immediate priority.
This aligns with ABCs.
• B (Incorrect): Chest x-ray may be useful later but is not
emergent and should not delay bronchodilator therapy.
• C (Incorrect): IV access may be needed but is secondary to
immediate bronchodilator delivery, which can often be
given via nebulizer or MDI with spacer.
• D (Incorrect): Auscultation is part of assessment but does
not treat the life-threatening bronchospasm; do not delay
treatment to perform only assessment.
Clinical principle: Prioritize airway/breathing
interventions; treat first, then investigate.
4
A school-age child is diagnosed with type 1 diabetes mellitus.
When teaching the family about insulin administration, the
nurse should emphasize:
A. Use the dorsogluteal site for consistent absorption.
B. Rotate injection sites within the same anatomical region.
C. Store all insulin vials in the freezer when not in use.
D. Always draw multiple insulins into the syringe in any order.
Correct answer: B
