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Testing Strategies for the
NCLEX-RN
Examination
CHAPTER ONE
One of the first steps to be being successful on the NCLEX® (National Council Licensure Examination) is to understand how the test is developed. An important step in preparing for the examination is to find out as much as possible about the test; this will help to reduce stress and anxiety. During each of your nursing classes, you were given a syllabus with course objectives and provided with presentations to guide you through the information that would be included on the next test. In most academic settings, the faculty member who teaches the course is also responsible for the develop- ment and construction of examinations—thus you are being taught by the same person who prepares the tests, which can be a great advantage. As you begin to prepare for the NCLEX, it is important to consider who determines the content of the test plan and constructs the questions based on the test plan. The National Council of State Boards of Nursing (NCSBN) is responsible for the development of the content and the construction of questions or items for the NCLEX examination. A practice analysis is conducted by the NCSBN every 3 years to validate the test plan and to determine cur- rency of nursing practice. Content experts are consulted to assist in the creation of the practice analysis. The activity performances and knowledge identified by the content experts are analyzed with consideration given to frequency, as well as importance of the nursing activity. The percentage of test items on the test plan does not specifically address specialty areas. However, on review of the nursing activities, many of the test plan areas address specialty areas of nursing practice. This analysis provides the basis for development of the content to be included in the NCLEX Test Plan. The content experts are practicing nurses who work with or supervise new graduates in the practice setting. These content experts represent all geographic areas and are selected according to their area of practice; therefore all areas of nursing practice are addressed in the development of the test plan. Item writers are selected to create questions based on the content identified in the test plan. All new test items or questions are reviewed by item reviewers who are also nurses in current practice and who have been directly involved with supervision of new graduate nurses. Not only do content experts and item reviewers create new items, they
are also involved in the continual review of items in the NCLEX test pool to ensure all items reflect current practice.^1 So, what does this all mean? It means that nurses in current practice and nursing faculty work together to iden- tify the content and to develop questions for the NCLEX- RN. All geographic areas, as well as all areas of nursing practice, are included. The purpose of the examination is to assure the public that each candidate who passes the exami- nation can practice safely and effectively as a newly licensed, entry-level RN. The NCLEX-RN is used by every U.S. state to deter- mine entry into nursing practice as an RN. Each state is responsible for the testing requirements, retesting proce- dures, and entry into practice within that state. Each state requires the same competency level or passing standard on the NCLEX; there is no variation in the passing standard from state to state.
TEST PLAN
The test plan is based on research conducted by the NCSBN every 3 years. The purpose of this research is to determine the most important and frequent activities of nurses who were successful on the NCLEX and who have been working after successful completion of the NCLEX. The research indicates that the majority of graduate nurses are working in an acute care environment and are responsible for caring for adult and elderly adult clients. Each question will reflect a level of the nursing process or an area of client needs, and each question will be categorized according to a validated level of difficulty. The exam consists of questions that are designed to test the candidate’s ability to apply the nursing process and to determine appropriate nursing responses and interventions to provide safe nursing care.
Integrated Processes Integrated throughout the test plan are principles that are fundamental to the practice of nursing.
Nursing Process The nursing process is a scientific approach to problem solving; it has been a common thread in your nursing
curriculum since the beginning of school. There is nothing new about the nursing process on the NCLEX. Assessment data are obtained, analysis of those data occurs, a plan is formulated, nursing actions are implemented, and the results of that intervention are evaluated. It is important to keep the steps of the nursing process in mind when you are criti- cally evaluating an NCLEX question.
Caring
The interaction of the client and the nurse occurs in an atmosphere of mutual respect and trust. To achieve the desired outcome, the nurse provides hope, support, and compassion to the client.
Communication and Documentation
Events and activities—both verbal and nonverbal—that involve the client, the client’s significant others, and the health care team are documented in handwritten or elec- tronic records. These records reflect quality and account- ability in the provision of client care. Principles of documentation and provision of client confidentiality are important considerations in any area of nursing practice.
Teaching and Learning Nurses provide or facilitate knowledge, skills, and attitudes that promote a change in clients’ behavior through teaching and learning. Nurses provide education to clients and to their significant others in a variety of settings. Identifying critical learning needs for clients and their significant others and providing information in a manner that promotes the health and safety of clients are important across all levels of nursing practice.^2
Areas of Client Needs The National Council Examination Committee has identi- fied four primary areas of client needs, which provide a structure to define nursing actions and competencies across all practice settings and for all clients. These areas reflect an integrated approach to the testing content; no predeter- mined number of questions or percentage of questions pertain to any particular area of practice (e.g., medical- surgical, pediatric, obstetric). Table 1-1 lists the areas of client needs, along with the subcategories and the specific percentages associated with each subcategory. The range of percentages for each
Table 1-1 NCLEX-RN®^ TEST PLAN—EFFECTIVE APRIL 2010 TO APRIL 2013*
Safe and Effective Care Environment
Management of Care (16%-22%) Concepts of management of nursing care—supervision, delegation, establishing priorities in client care; legal and ethical responsibilities; client rights; confidentiality Safety and Infection Control (8%-14%) Prevention of errors and accidents, implementation of standard precautions, asepsis, use of restraints, disaster planning, handling hazardous materials Health Promotion and Maintenance (6%-12%)
Aging process and developmental stages, lifestyle choices, high-risk behaviors; principles of learning and teaching; ante/intra/postpartum and newborn; health promotion and disease prevention, techniques of physical assessment Psychosocial Integrity (6%-12%)
Mental health concepts and interventions, end-of-life care, grief and loss, sensory and perceptual alterations, religious and spiritual influences; behavioral intervention/crisis intervention, chemical dependency, abuse and neglect, therapeutic communication Physiologic Integrity
Basic Care and Comfort (6%-12%) Assistive devices, mobility, nutrition, personal hygiene, elimination, nonpharmacologic comfort measures Pharmacologic and Parenteral Therapies (13%-19%)
Medication administration; expected medication actions, adverse effects/contraindication; nursing implications; dosage calculation; blood administration, parenteral/IV therapy, central venous access devices, pain control, parenteral nutrition Reduction of Risk Potential (10%-16%) Pathophysiology, nursing implications for and nursing care to minimize potential complications of diagnostic tests/procedures/surgery; potential for alterations in body systems (tubes, pacemakers, hyper/hypoglycemia, specimens, bleeding, immobility, wounds, positions); laboratory values; changes in and/or abnormal vital signs; system specific assessments Physiologic Adaptation (11%-17%) Pathophysiology/alterations in body systems: fluid and electrolyte imbalances, hemodynamics, medical emergencies (CPR, airway, hemorrhage), unexpected response to therapies (seizures, changes in vital signs); nursing management of illness
Adapted from the NCLEX-RN ®^ Test Plan for the National Council Licensure Examination for Registered Nurses, Chicago, 2009, National Council of State Boards of Nursing. *Test plan information is presented as examples only and is not intended to be a complete or thorough representation of information included in any specific category.
how to use the computer on NCLEX is available at www. pearsonvue.com/nclex/. Go to the site and review the tutorial. It should be very familiar to you when you see it on NCLEX. This same tutorial will be presented to you at the beginning of your examination.
Testing Center Identification Photo identification with a signature and the ATT will be required at the testing site. The name printed on the ATT must match the identification presented at the course site. Identification must be in English and cannot be expired. Acceptable forms of identification are a U.S. driver’s license, a passport, or a U.S. state-issued identification, or a U.S. military issued identification. At the testing site before testing, each candidate will be digitally fingerprinted, a photo will be taken, and a signature will be required. Beginning in 2009, a new type of identity verification will be used in some testing locations. A Palm Vein Reader may be used at some testing sites, in addition to the digital fingerprinting, to validate identity on reentering the testing area.
Day of the Examination You should plan on arriving at the center about 30 minutes before scheduled testing time. If you arrive more than 30 minutes late, the scheduled testing time will be canceled and you will have to reapply and repay the examination fee. An erasable note board will be available at your com- puter terminal. You are not allowed to take any type of books, personal belongings, hats, coats, blank tablets, or scratch paper into the testing area. A fingerprint scan will be required to reenter the testing area after each break.
Testing You will have a maximum of 6 hours to complete the exami- nation. After 2 hours of testing, you have an optional 10-minute break; another optional break occurs after 3 1/ hours of testing. If you need a break before that time, notify one of the attendants at the testing center. The computer will automatically signal when a scheduled break begins. All
TAKING THE NCLEX®^ EXAMINATION
Application
An application must be submitted to the state board of nursing in the state in which the candidate wants to be licensed. The contact information for the state boards of nursing is available on the National Council website. After the candidate’s application and registration fees have been received and approved by the state, the candidate will receive an a uthorization t o t est (ATT) from the NCSBN. After the examination fee has been paid, it will not be refunded, regardless of how the candidate registered. 3 The candidate may register for the NCLEX at the NCLEX Candidate website (listed in the ATT) or by regular mail or by tele- phone (also listed in the ATT). The Candidate Bulletin (CB) is available on the National Council website—be sure to print this bulletin for future reference. The CB provides critical information, including addresses and phone numbers for registration and specific details regarding the registration process.
Scheduling the Examination
After you have been declared eligible to take the NCLEX and have received an ATT, you may schedule an examina- tion date. You must have an ATT before you can schedule your examination. The CB lists the phone number to call to schedule the examination. Once the ATT has been issued, the state stipulates a period of time within which you must take the examination. This ranges from 60 to 365 days, with the average being 90 days; this period cannot be extended. You must test within the validity dates noted on your ATT. The ATT must be presented at the testing site before you can be admitted to take the examination. You are encouraged to call and schedule the appointment to take the examination as soon as possible after receiving the ATT, even if you do not plan to take the test imme- diately. This will increase the probability of getting the testing date you want. Pearson Vue is the company that provides the testing facility and computers for the examination. A tutorial on
Passing level of difficulty
Decision: Fail
of questions
0 10 20 30 40 50 60 70 75
Passing level of difficulty
of questions
0 10 20 30 40 50 60 70 75
Decision: Pass
FIGURE 1-2 Plateau to establish pass or fail.
Being able to effectively apply test-taking strategies on an examination is almost as important as having the basic knowledge required to answer the questions correctly. Everyone has taken an examination only to find, on review of the exam, that questions were missed because of poor test-taking skills. Nursing education provides the graduate with a comprehensive base of knowledge; how effectively the graduate can demonstrate the use of this knowledge will be a major factor in the successful completion of the examination. The NCLEX-RN is designed to evaluate minimum levels of competency. The exam does not test total knowl- edge, knowledge of specialty areas, or any degree of profes- sionalism. The purpose of the examination is to determine whether a candidate has the knowledge, skills, and ability required for safe and effective entry-level nursing practice. Throughout the examination, questions are described as being based on clinical situations common in nursing; uncommon situations are not emphasized. NCLEX ques- tions are not fact, recall, or memory-level questions; they are questions that require critical thinking to determine the correct answer. Critical thinking will require an analysis of client data, an understanding of the client’s condition or disease, and the ability to determine the best action or nursing judgment that will most effectively meet the client’s needs. Practice testing is an excellent method of studying for the NCLEX. After taking a practice test, use the results to determine whether you need additional review in certain areas or whether you are missing questions because of poor test-taking strategies.
NCLEX®^ TEST-TAKING STRATEGIES
The NCLEX questions are different from those used in nursing schools. One of the biggest problems candidates encounter is that two or more answers may appear to be correct. Sometimes a candidate believes that more informa- tion is necessary to answer the question. However, the answer must be determined from the information provided; no one is going to clarify or provide additional information regarding a specific question or content. The strategies described below are critical in evaluating and successfully answering NCLEX questions.
- The NCLEX Hospital: What a great place to work! Remember, on the NCLEX, all clients are being cared for in an ideal environment—the NCLEX Hospital. Questions ask for nursing care and decisions based on situations in which everything is available for client care.
of the break times and the tutorial are considered part of the total 6 hours of testing time. The examination will stop when one of the following occurs:
- Seventy-five questions have been answered, and a minimum level of competency has been established; or a lack of minimum competency has been established (see Figure 1-2).
- The candidate has answered the maximum number of 265 questions.
- The candidate has been testing for 6 hours, regardless of the number of questions answered. Each candidate will receive between 75 and 265 ques- tions. The number of questions on the NCLEX is not indicative of the level of competency. The majority of can- didates who complete all 265 questions will have demon- strated a level of minimum competency and therefore pass the NCLEX. A mouse will be used for selecting answers, so candidates should not worry about different computer key- board function keys. An onscreen calculator will also be available to use for math problems. If any problems occur with the environment or with the equipment, someone will be available to provide assistance. In each candidate’s examination, there will be 15 pretest or unscored items or questions. The statistics on these items will be evaluated in order to determine whether the item is a valid test item to be included in future NCLEX test banks. All of the items that are scored, or counted, on a candidate’s examination have been pretested and validated. It is impos- sible to determine which questions or items are scored items and which are pretest items. It is important to treat each question as a scored item. The CB from the NCSBN is very important; read it carefully and keep it until the results from NCLEX have been received. This bulletin will provide directions and will answer more of your questions regarding the NCLEX. The CB is available online (from the NCSBN at www. ncsbn.org or from Pearson Vue at www.pearsonvue.com/ nclex ).
Test Results
Each examination is scored twice, once at the testing center and again at the testing service. The test results are electronically transferred to the state boards of nursing. Test results are not available at the testing center, from Pearson Vue, or from the NCSBN. Check the informa- tion received from the appropriate state board of nursing to determine how and when your results will be available. Test results may be available online. In some states, results may be available within 2 to 3 days; in others, the results will be mailed, which will require a longer notification period. Do not call the Pearson Pro- fessional Center, NCLEX Candidate Services, the National Council, or the individual state board of nursing for test results. Follow the procedure found in the information from the state board of nursing where the license will be issued.^3
ALERT Practicing test-taking skills is critical if a candidate is going to be able to effectively use them on the NCLEX. Practice test taking should be a component of NCLEX preparation.
SUCCESSFUL TEST TAKING ON THE
NCLEX®^ EXAM
ation with a client may be presented, and you will be asked to select the first nursing action. Review the testing strategies regarding priority questions. It is important to identify the most unstable client, to see him or her first, and to determine what is necessary to do first for this client.
Establishing Nursing Priorities Almost all nurses will agree that the NCLEX is full of prior- ity questions. These questions may be worded in a variety of ways: “What is the priority nursing action?” “What should the nurse do first?” “What is the best nursing action?” In other words, the NCLEX wants to know whether the nurse can identify the most important nursing action to be taken in order to provide safe care for the client in the situ- ation presented. In such cases, three or four of the options are frequently correct actions; however, one of the actions needs to be performed before the others. This is where criti- cal thinking is necessary— think like a nurse! There are three areas to consider when determining priority nursing actions: Maslow’s hierarchy of needs, the nursing process, and client safety.
- Maslow’s Hierarchy of Needs: And you thought this was just for fundamentals! Always consider Maslow’s hier- archy of needs and remember that physiological needs must come first. When evaluating options, identify client needs that are physiologic and those that are psychosocial. Physiologic needs are a higher priority than psychosocial or teaching needs. A client’s physical needs must be met before his or her psychosocial or teaching needs are con- sidered. Also remember that the ABCs (airway, breath- ing, and circulation) are the critical physiologic needs because these are at the base of Maslow’s pyramid. However, be cautious— don’t always select “airway” as the best answer. Sometimes the client does not have an airway problem, so don’t read that into the question and give the client an airway problem! Maslow’s hierarchy of needs also applies to psychosocial questions (see the section in this chapter regarding answering psychosocial questions).
- Nursing Process: The first step in the nursing process is assessment. However, do not automatically select an option that includes the word assess or an option that involves assessment. Assessment must be done to analyze and construct a nursing diagnosis, to develop a plan of care, and to determine the priority of nursing care imple- mentation. If the assessment data are provided in the stem of the question, then it will be important to consider Maslow’s hierarchy of needs when planning or selecting the best nursing action or implementation. If a nursing action has been implemented, then the question may focus on evaluating the effectiveness of the nursing action. Read the question carefully and determine what is being asked.
- Safety Issues: These issues may include situations in the hospital or in the client’s home environment. The first
or licensed vocational nurses [LVNs]) have more inde- pendence in providing nursing care. They may direct the care of the nursing assistants. However, LPNs are ulti- mately under the supervision of a registered nurse. Don’t panic and pull out all your management textbooks to review. Evaluate such questions in terms of general guide- lines for delegation and supervision. Pay close attention to the person to whom the nurse is assigning the care or nursing activity: Is it to another RN, is it to a less qualified person (LVN or LPN), or is a specific activity (bathing, ambulating, etc.) being delegated to an unlicensed nursing assistant?
- Don’t assign steps of the nursing process or nursing judgment to anyone except an RN. The implementation of the nursing process and the judgments based on the nursing process must be performed by an RN.
- Don’t delegate teaching assignments to anyone except another RN. This is another area that is the primary responsibility of the RN.
- Keep in mind the NCLEX Hospital. Adequate staff is available to provide client care; don’t worry about staff shortages. Focus on the needs of the client in the ques- tion; what is happening in the rest of the unit is not a consideration unless it is part of the actual question. The only client to consider in each question is the one involved in that question, not the other clients the nurse may have been assigned.
- Identify the most stable client. The most stable client is the one who has the most predictable outcome and is least likely to have abrupt changes in condition that would require critical nursing judgments. For stable clients, some nursing care activities can be delegated to a nursing assistant or assigned to an LPN. When determining the stability of clients, Maslow’s hierarchy of needs must be considered (see Chapter 3, Figure 3-1). Very carefully assess and identify clients who are in a changing unstable situation, especially those clients with a potential for respiratory compromise. These are clients for whom an RN should provide the care.
- Delegate tasks that have specific guidelines. Those tasks that have specific guidelines that are unchanging and are used in the care of a stable client can often be delegated. Bathing, collecting urine samples, feeding, providing personal hygiene, and assisting with ambula- tion are just a few examples of these activities. Remember you are in the NCLEX Hospital, so carefully evaluate the question and select an answer that has the RN del- egating tasks to the assistive personnel and making appropriate assignments for other licensed health care personnel.
- Identify your priority client. The priority client is the one who is most likely to experience problems or ill effects if not taken care of first. Priority clients include those with respiratory compromise, those whose condi- tions are unstable and changing, and those who are at high risk for developing complications. NCLEX ques- tions may present a typical nursing care assignment and ask which client the nurse would care for first; or a situ-
Answer: 4. The client with chest pain is at greatest risk of experiencing immediate problems. This client needs to be evaluated immediately. Option 1, the client who had surgery, is experiencing pain. This is important but not alarming. Pain control needs to be addressed as soon as possible. In option 2, the client with increased lethargy and confusion needs to be evaluated. The confusion and lethargy are increas- ing; therefore, they were present prior to this time. These are psychosocial needs that need to be addressed; however, with the information presented, they do not represent an immediate physical problem. The newly admitted client in option 3 has a slightly elevated BUN level. This could be related to hydra- tion problems, but the client is not presented in an unstable situation.
Question 3 A cardiac client turns on his call light and tells the nurse he is experiencing chest pain. What is the first nursing action?
- Administer oxygen to the client at 4 L/min through a nasal cannula.
- Assess heart sounds for the presence of ectopic beats.
- Auscultate breath sounds and maintain airway.
- Determine what the client was doing before the onset of pain. Answer: 1. When a client complains of chest pain, oxygen should be started immediately and then vital signs should be further assessed. In the stem of the question, a cardiac client with chest pain is presented; that is enough critical assessment information for a nursing action. It is assumed that the nurse has an order for the oxygen. Further assessment will determine the status of the vital signs, and options 2 and 4 can be com- pleted. Listening for ectopic beats and determining breath sounds are assessment activities; however, this does not provide further definitive information for determining immediate nursing care. In option 4, whether physical exertion was a factor in the occur- rence of the chest pain can be determined later, but this is not an immediate concern. Option 3 gives this client airway prob- lems, and there is no indication in the stem that the airway is an issue at this time.
Question 4 A client has returned from abdominal surgery, and the nurse is assessing the incisional area. The dressing has some bright red blood on it, and on closer inspection, the nurse deter- mines that there is a loop of bowel protruding. What is the best nursing action?
- Remove the dressing and place a sterile dressing soaked in saline on the wound with dry reinforcement dressings on top.
- Remove the dressing and with sterile gloves apply very gentle pressure to replace the exposed bowel.
- Leave the dressing in place and apply an abdominal pres- sure dressing to prevent further exposure of the bowel.
- Immediately notify the health care provider and then cleanse the wound area with sterile saline solution and replace the dressing.
issue to consider is meeting basic needs of survival: oxygen, hydration, nutrition, elimination. Reduction of environmental hazards is also a concern and may include prevention of falls, accidents, and medication errors. Environmental safety also includes the prevention and spread of disease. This may include how to avoid contagious diseases or even activities such as handwash- ing. When you are critically evaluating questions that involve a client’s safety and multiple options appear to be correct, determine what activity will be of most benefit to the client.
Example Questions for Management and Priority Setting
Question 1
An RN who has been working in the labor and delivery area has been reassigned to a step-down telemetry unit for the afternoon shift. Which clients would reflect the most appro- priate assignment for this nurse?
- Client who has undergone cardioversion and a client who was admitted during the night for possible myocardial infarction (MI).
- Client who had a cardiac catheterization this morning and a client admitted for 24-hour observation for first- degree heart block.
- Client who is currently in third-degree heart block and a client who had a hypertensive crisis with congestive heart failure 48 hours ago.
- Client who had an MI 72 hours ago and is experiencing an increase in premature ventricular contractions (PVCs) and a newly admitted client with paroxysmal onset of atrial fibrillation. Answer: 2. The labor and delivery RN needs to be assigned the most stable clients and the ones with the most predictable prognoses—these are the clients in option 2. Do not read into the situation and give the client who has had cardiac catheter- ization more problems. In option 1, the client who had a possible MI 16 hours ago is at risk for complications, as is the client who underwent cardioversion. In option 3, the client with third-degree heart block is most likely very unstable and may need a pacemaker. In option 4, the client who has had an MI is demonstrating signs of ventricular irritability, and the client with atrial fibrillation will need to be evaluated.
Question 2
The nurse is assigned a group of clients for care. Which client would the nurse assess first?
- A client who had surgery 2 days ago and who is com- plaining of pain.
- An older adult client reported to have increasing confu- sion and lethargy.
- A newly admitted client with a serum blood urea nitro- gen (BUN) level of 32 mg/dL.
- A hypertensive client complaining of epigastric discom- fort and midsternum chest pain.
Example: A bronchoscopy was performed on a client at 7: AM. The client returns to his room, and the nurse plans to assist him with his morning care. The client refuses the morning care. What is the best nursing action regarding the morning care for this client?
- Perform all of his morning care to prevent him from becoming short of breath.
- Avoid morning care and continue to monitor vital signs and assess swallowing reflexes.
- Postpone the morning care until client is more comfort- able and can participate.
- Cancel all of the morning care because it is not necessary to perform it after a bronchoscopy. The correct answer is 3. The question is asking for a nursing judgment regarding morning care. Do not read into the question and make it more difficult by trying to put in information relat- ing to respiratory care, such as checking for gag and swallowing reflexes.
- Read the stem correctly. Make sure you understand exactly what information the question is asking. Determine whether the question is stated in a posi- tive (true) or negative (false) format. Watch for words that provide direction to the question. A positive or true stem may include the following: “indicates the client understands,” “the best nursing action is,” “the preoperative teach- ing would include,” or “the best nursing assignment is.” Also watch for words in the stem that have a
- Watch where the client is in the disease process or condition he or she is experiencing. Examples of this are phrases such as “immediately postopera- tively,” “the first postoperative day,” and “experi- enced a myocardial infarction this morning.”
Example: Clients with arteriosclerotic heart disease (ASHD) go through several stages before becoming severely compro- mised. In considering the pathophysiology of heart disease, the nurse would identify what physical response that does not occur in the early stages of ASHD?
- Decreased urine output
- Dyspnea on exercise
- Anginal pain relieved by rest
- Increased serum triglyceride levels Rephrase the question: What is not a characteristic finding in the early stages of ASHD? It is important to identify the key point “early stages of ASHD” and the key words “does not occur.” If you miss these essential points, you do not understand the question, and chances are you will not choose the correct answer. The correct answer is option 1; a decrease in urine output occurs when cardiac disease is advanced enough to cause a severe decrease in cardiac output and renal perfusion. All the other options occur earlier in ASHD.
Example: A client had a cardiac catheterization through the left femoral artery. During the first few hours after the cardiac catheterization procedure, which nursing action would be most important? Rewording: What is the most important nursing care in the first few hours after a cardiac catheterization?
- Check his temperature every 2 hours and monitor cath- eter insertion site for inflammation.
- Elevate the head of his bed 90 degrees and keep affected extremity straight.
- Evaluate his blood pressure and respiratory status every 15 minutes for 4 to 6 hours.
- Check his pedal and femoral pulses every 15 minutes for first hour, and then every 30 minutes. The correct answer is 4. The phrase, “during the first few hours after the procedure,” is important in answering this question correctly. The danger of hemorrhage and hematoma at the punc-
- Read the question carefully before ever looking at or considering the options. If you glance through the options before understanding the question, you may pick up key words that will affect the way you perceive the question. It is important to understand the question and not formulate an opinion about the answer before you understand the question. On a paper-and-pencil test, cover the answers with your hand or a note card. If you practice this strategy before taking the NCLEX, you will be able to focus on the question without physically covering the answers when taking a test on the computer.
Specific Strategies and Examples of Multiple-Choice Questions
negative meaning so that the question is asking for a response that is not accurate or is false. Phrases such as “is contraindicated,” “the client should avoid ,” “indicate the client does not understand ,” “does not occur,” and “indicates [medication, equipment, nursing action] is not working ” are negative indica- tors. The question is asking for information that is not accurate or actions the nurse would not take. The following words or phrases change the direction of the question: except, never, avoid, least, contraindi- cated, would not occur. It may help to rephrase the question in your own words to better understand what information is being requested.
- Do not read extra meaning into the question. The question is asking for specific information; if it appears to be simple “common sense,” then assume it is simple. Do not look for a hidden meaning in a question. Avoid asking yourself “what if …?” or speculating about the future (“maybe the client will …”). Don’t make the client any sicker then he or she already is!
- Call the residential facility and ask for an incident report.
- Put ice on the bruises and cover the abrasions with pro- tective gauze.
- Notify the supervisor regarding the possibility of an abusive situation.
- Perform a head-to-toe assessment and determine the extent of the injuries. The correct answer is 4, to determine or assess the extent of inju- ries. The stem of the question did not present adequate informa- tion with which to make a nursing judgment, and the client’s physiologic needs are the priority. Option 1 does not immediately alleviate pain or assist the client. Options 2 and 3 relate to nursing actions that may be done after the immediate injuries and needs have been assessed. Focus on the client; priority setting and physiologic needs must be addressed first.
ture site is greatest during this time. The question also asks for the most important nursing care. Option 3: it is important to evaluate vital signs, but it is not required that they be evaluated every 15 minutes for 4 to 6 hours if client is stable. Option 4 is critical in the first few hours following a cardiac catheterization.
- Identify the step in the nursing process being tested. Remember, you must have adequate assess- ment data before you move through the steps of the nursing process. Is there adequate information pre- sented in the stem of the question to determine appropriate nursing planning or intervention? Is the correct nursing action to obtain further assessment data? Look for key words that can assist you in determining what type of information is being requested.
- Before considering the options, think about the characteristics of the condition and critical nursing concepts. What are the nursing priorities in caring for a client with this condition/procedure/medica- tion/problem?
Example: A woman who gave birth 3 days ago returns to the clinic with complaints of soreness and fullness in her breasts and states that she wants to stop breastfeeding her infant until her breasts feel better. What is the best nursing response? This is a positive question. The answer will be a true state- ment. Think about breastfeeding and the common discomforts and problems the client encounters. Don’t look at the options yet. Think, “Is it normal to have fullness and soreness in the breasts during the first 3 days of lactation, and what happens if she stops breastfeeding the infant?” Now evaluate the options:
- Show the client how to apply a breast binder to decrease the discomfort and the production of milk.
- Tell the client that breast fullness may be a sign of infec- tion and she will not be able to continue breastfeeding.
- Suggest to the client that she decrease her fluid intake for the next 24 hours to temporarily suppress lactation.
- Explain to the client that the breast discomfort is normal and that the infant’s sucking will promote the flow of milk. In this question, option 4 is correct. Initially, breast soreness may occur for about 2 to 3 minutes at the beginning of each feeding until the let-down reflex is established. Options 1, 2, and 3 would decrease her milk production; the question did not state that she wanted to quit breastfeeding permanently.
- Confused at this point? What if, after reading the question, you aren’t sure what the question is even asking? Take a deep breath, reread the question, and ask yourself, “What is the main topic of the ques- tion?” Now read the option choices, not to eliminate options or select a correct answer, but to get a clue as to the direction of the question. It might be helpful to read the options from the bottom up (start with option 4, rather than option 1) to help your brain focus on the options.
Example: A mother brings in a toddler with pediculosis capitis. A prescription of 1% permethrin (Nix) is given to her. What is important for the nurse to teach the mother? Ask yourself: Is the question asking about prevention of pedic- ulosis, complications, prevention of spread of the disease, or treat- ment? Check out the options. Is there an indication in the options as to the direction of the question?
- Medication should be applied daily for 1 week with an additional follow-up treatment in 7 days.
- Clothing, toys, and personal belongings of other family members do not require any special care.
- Solution should be applied today and be applied again if nits are still visible in 24 hours.
- Allow the medication to remain in contact with the scalp for 10 minutes and then thoroughly rinse. After checking out the options, it appears that the question is asking for teaching implications for the mother regarding the use of the medication, Nix. Now that you have determined what you need to identify, you can begin the process of elimina- tion of the options until you have found the correct answer. The correct answer is 4. The Nix solution needs to remain on the scalp for 10 minutes before the hair is rinsed. Option 1 is too frequent for the medication to be used. Option 2 is incorrect, because the child’s clothing and toys, as well as clothing and toys of the siblings, will need to be treated. Option 3 is not correct because medication should be reapplied in 7 days.
Example: An 85-year-old client from a residential care facil- ity is brought into the emergency department. Numerous bruises and abrasions in various stages of healing are present on the client’s face and arms. The attendant from the resi- dential facility explains that the client fell down. What is the priority nursing action?
Example: The nurse is obtaining a specimen from a client’s incisional area for a wound culture and sensitivity. What client information will the sensitivity part of the procedure reflect?
- Presence and characteristics of all bacteria present in the client’s wound
- Which antibiotics will effectively treat the bacteria present
- Differentiation of the bacteria and viruses present in the wound
- All the treatments to which the bacteria are responsive Options 1 and 4 contain the word “all.” If you did not know the answer, you could eliminate options 1 and 4. Identifying all the bacteria and all the treatments is not feasible from a culture and sensitivity. This would give you a 50% chance of finding the right answer, which is option 2.
- Gestational age (Yes, this is true; ultrasonography gives an overall picture of bone formation [biparietal diameter (BPD)], thereby indicating gestational age.)
- Rh factor antibody level (No, this is false; this level must be determined by a blood test to evaluate for isoimmunization or hemolytic disease of the newborn.) After a systematic evaluation of the options, option 3 is the correct answer.
- Identify similarities in the options. Frequently, the options will contain similar information, and some- times you can eliminate similar options. If three options are similar, the different one may be the correct answer. When two of the options are very similar and one of those options is not any better than the other, both of them are probably wrong, so start looking for another answer. Sometimes three of the options have very similar characteristics; the option that is different may be the correct answer.
Example: The nurse is assisting a client to identify foods that would meet the requirements for a high-protein, low- residue diet. Which foods would represent correct choices for this diet?
- Roast beef, slice of white bread.
- Fried chicken, green peas.
- Broiled fish, green beans.
- Cottage cheese, tomatoes. Options 1, 2, and 3 all contain a meat or fish that would be needed for a high-protein diet; therefore option 4 can be elimi- nated. Options 2, 3, and 4 all contain a vegetable that has a skin, making these high-residue choices. The correct answer is option 1, for both high-protein and low-residue qualities. Note that the NCLEX will not focus on dishes that contain a mixture of foods, in which you would need to know the recipe to answer correctly. Also, unless specified, do not attribute special character- istics to a food; if a food has a special characteristic, it will be stated (e.g., “low sodium” soup or “low fat” yogurt).
- Some questions may have options that contain several items to consider. After you are sure you understand what information the question is request- ing, evaluate each part of the option. Is the option appropriate to what the question is asking? If an option contains one incorrect item, the entire option is incorrect. All of the items listed in the option must be correct if that option is to be the correct answer to the question.
- Select the most comprehensive answer. All of the options may be correct, but one option may include the other three options or need to be consid- ered first.
- Identify words in the options that are “qualifiers.” Every, none, all, always, never , and only are words that have no exceptions. Options containing these words are frequently incorrect. Seldom in health care is anything absolute with no exceptions; thus you can often eliminate these options. In some situations the qualifiers are correct, especially when a principle or policy is described. For example, the nurse always establishes positive client identification before administering medications. This would be a correct statement. Carefully evaluate qualifiers; they are clues to the correct answer.
Example: The nurse is planning to teach a client with dia- betes about his condition. Before the nurse provides instruc- tion, what is most important to evaluate? The client’s:
- Required dietary modifications.
- Understanding of the exchange list.
- Ability to administer insulin.
- Present understanding of diabetes. Options 1, 2, and 3 are certainly important considerations in diabetic education. However, they cannot be initiated until the nurse evaluates the client’s knowledge of his or her disease state. When two options appear to say the same thing, only in different words, then look for another answer; that is, eliminate the options that you know are incorrect. Options 1 and 2 both refer to the client’s understanding of nutrition.
Example: In evaluating the lab data of a client experiencing renal failure, the nurse would identify what findings as indic- ative of increasing renal failure?
- Increased BUN level, hyperkalemia, decreased creatinine clearance
- Increased hemoglobin, hyponatremia, increased urine electrolytes
adult client is a significant physiologic change, often an infection (commonly in the urinary tract) or dehydration. Options 1 and 3 relate more to the gradual behavior changes seen in the progres- sion of dementia and do nothing “to determine the possible cause …” Option 2 also does not provide any assistance in determining the cause of the behavior change; further nursing assessment needs to be conducted before calling for assistance.
Alternate Format Questions In an effort to improve and more effectively assess the entry- level nurse, the NCSBN has introduced “alternate format questions” to the examination. These questions were included on the NCLEX beginning in April 2003. There is no estab- lished percentage of alternate format items a candidate will receive. The alternate format questions that have been previ- ously validated are placed in the test item pools and are randomly selected to meet the items on the test plan and the established level of difficulty. The NCSBN has not specified a number of alternate format questions that will be included in a candidate’s test bank. A candidate should expect several alternate format questions. It is important to consider that there will be 15 pretest or unscored items in the first 75 questions on every candidate’s examination. Within those 15 items, there may be several unscored alter- nate format items. It is important to answer all the questions to the very best of your ability because you do not know which questions are scored items and which are unscored items.3, The alternate format questions should not have any impact on what you study or how you study. The content on the alternate format questions is from the same test plan as the other questions. The test-taking strategies are essen- tially the same with minor modifications. In other words, there is no reason to be alarmed about the alternate format questions; they are testing the same information, just in a different type of question.
- High fasting blood glucose level, increased prothrombin time
- Increased platelets, increased urine specific gravity, proteinuria Option 1 is correct. In a methodic evaluation of the items in the options, you can eliminate options. The item “increased hemoglo- bin and urine electrolytes” in option 2 and the item “increased urine specific gravity” in option 4 make these two options incor- rect. Option 3 has nothing to do with renal failure; the blood glucose level is associated more with diabetes and endocrine problems.
The nurse is caring for an 85-year old client who has a diagnosis of Mycoplasma pneumonia. What precautions will the nurse implement in assisting the client with morning care? Select all that apply:
- Wear clean gloves.
- Remove all extra suctioning supplies from the room.
- Dispose of the gown and mask in container outside client's door.
- Wear face mask when working within 3 feet of the client.
- Put on a gown prior to entering the room.
- Remove the stethoscope from the room if it did not come in contact with the client.
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ITEM 21
Answer: The answer is based on standard precautions, plus respiratory precautions for the pneumonia. Nothing should be removed from the room and the gown should be removed prior to leaving the room, not outside the room.
Multiple Response
FIGURE 1-4 Alternate format question—multiple response.
- After you have selected an answer, reread the ques- tion. Does the answer you chose give the informa- tion the question is asking for? Sometimes the options are correct but do not answer the question.
Example: A client is 88 years of age and has previously been alert, oriented, and active. The nursing assistant reports that on awakening this morning, the client was disoriented and confused. What initial action would the nurse take to deter- mine the possible cause of this change in the client’s behavior?
- Review the history for any previous episodes of this type of behavior.
- Call the health care provider and discuss the changes in the client’s behavior.
- Do a thorough neurologic evaluation to evaluate the spe- cific changes in behavior.
- Evaluate for the presence of a urinary tract infection and for adequate hydration. Option 4 is the only answer that supplies what the question asked for (“determine the possible cause of this change”). The most common cause of a sudden change in the behavior of an older
The nurse is caring for a client with pneumonia. He is dyspneic, his temperature is 102°F orally, and he is complaining of chest pain. In what order would the nurse provide care for this client? Place all of the actions below in the order of priority for nursing care. Use all of the options. Unordered options: Ordered Response: Encourage clear fluids Place in Semi-Fowler’s position Administer humidified oxygen Administer humidified oxygen Place in Semi-Fowler’s position Administer anti pyretic medication Instruct client regarding risk factors
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ITEM 23
This question is asking you to provide care for a client who is experiencing difficulty breathing and has chest pain. The dyspnea^ Need to know: Review each of the items in the list. Determine what is the most important action to take first, then second, etc. and chest pain are most likely a result of the client's pneumonia. Position is the first thing that you can do that will benefit the client the most, then begin the oxygen, administer the antipyretic medication, encourage clear liquids, and teaching is last. Remember Maslow when setting priorities.
Drag and Drop
FIGURE 1-7 Alternate format question—ordered response (drag and drop).
the options present. Practice by considering how you would answer the question in Figure 1-7. Answer: The client should be placed in a semi-Fowler’s posi- tion before oxygen administration is started; an antipyretic medication should then be given. This action addresses current needs. Next, encourage intake of clear liquids to decrease viscosity of secretions. Finally, provide instruction regarding risk factors (psychosocial need).
Chart or Exhibit Items
In this type of question, a client situation or problem and client information are provided in a chart or an exhibit (Figures 1-8 through 1-12). To begin, click on the tab on the bottom of the screen to see the exhibit; then click on the tabs within the exhibit to find the information needed to answer the question. There may be several tabs to click on, check the information included within each tab, and deter- mine if it is pertinent to the situation. Interpretation of information: Client received morphine 10 mg IM at 11:00 AM; became lethargic and slept for the next 5 hours. He received hydrocodone PO at 4:00 PM and was com-
fortable for the next 4 hours. The doctor’s orders are current for both the IM and the PO medication for pain. Answer: 4. Give the hydrocodone, PO, for pain at this time. It is preferable to give a client a PO pain medication than a parenteral pain medication. The hydrocodone provided effective pain relief for 4 hours when it was administered the last time, and the doctor’s order is current.
Audio Questions Beginning in 2010. “audio” questions will be included on the NCLEX. The screen will tell the candidate to place the head phones on to listen to the information. The informa- tion may be replayed if necessary. After listening to the information, the candidate will select an answer from the options presented.
Therapeutic Nursing Process: Principles of Communication Throughout the examination there will be questions requir- ing use of the principles of therapeutic communication. In therapeutic communication questions, do not assume
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Section time remaining: 3:15. The nurse is caring for a client who is receiving .25 mg Digoxin each morning. On the graphic, identify the correct location where the nurse should place the stethoscope to determine the client's pulse.
[NCLEX-RN] Candid ate Name
ITEM 22
X
Answer: To evaluate the apical pulse the stethoscope should be placed on the area of the PMI - left midclavicular line, 5th intercostal space. To answer this question, you would simply click the area on the graphic. The correct location is noted in the figure.
Hot Spot
FIGURE 1-6 Alternate format question—hot spot.
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Select the best answer based on information in the exhibit. Click the Next (N) button or the Enter key to confirm answer and proceed.
A postoperative client complains of pain, the nurse assesses the client and determines the pain is in the abdomen around the area of the incision, pain level is 6. It is 8 p.m. in the evening and the nurse is determining what can be done regarding the client's pain. Select the best answer based on the information in the chart.
- Give morphine sulfate 15 mg IM now.
- Medication cannot be administered.
- Give morphine sulfate 10 mg IM now.
- Give hydrocodone (Vicodan) 10 mg PO.
ITEM 24
Chart or Exhibit
FIGURE 1-8 Alternate format question—exhibit item.
NursingNotes
1. Nursing notes: 8 a.m. – level 7, pain medication administered. complaining of abdominal pain around area of incision; pain 11 a.m.4 p.m. – – sleeping throughout the day, lethargic, but easily aroused.complaining of abdominal pain around incisional area, pain level 5, pain medication administered, was free of pain and restingcomfortably within 30 minutes. 6 p.m.8 p.m. – – remains comfortable.beginning to complain of abdominal incisional pain.
AdministrationMedication Records
Doctor'sOrders
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Select the best answer based on information in the exhibit. Click the Next (N) button or the Enter key to confirm answer and proceed.
A postoperative client complains of pain, the nurse assesses the client and determines the pain is in the abdomenaround the area of the incision, pain level is 6. It is 8 p.m. in the evening and the nurse is determining what can be done regarding the client's pain. Select the best answer based on the information in the chart.
- Give morphine sulfate 15 mg IM now.
- Medication cannot be administered.
- Give morphine sulfate 10 mg, IM now.
- Give hydrocodone (Vicodan) 10 mg PO.
FIGURE 1-9 Alternate format question—first tab on exhibit item.
NursingNotes 2 of 3
2. Medication administration record (MAR): Morphine sulfate 10 mg IM administered at 8 a.m. Hydrocodone 10 mg, PO administered at 4 p.m.
AdministrationMedication Records
Doctor'sOrders
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Select the best answer based on information in the exhibit. Click the Next (N) button or the Enter key to confirm answer and proceed.
A postoperative client complains of pain, the nurse assesses the client and determines the pain is in the abdomenaround the area of the incision, pain level is 6. It is 8 p.m. in the evening and the nurse is determining what can be done regarding the client's pain. Select the best answer based on the information in the chart.
- Give morphine sulfate 15 mg, IM now.
- Medication cannot be administered.
- Give morphine sulfate 10 mg, IM now.
- Give hydrocodone (Vicodan) 10 mg PO.
ITEM 24
FIGURE 1-10 Alternate format question—second tab on exhibit item.
the question, confirm your answer, and move on to the next question.
- Watch your timing. Do not spend too much time on one question. It is very important to track your timing on practice exams. This will help you be more comfort- able with timing on computer testing. The NCLEX will allow you a total of 6 hours to complete the examination. When you are taking a practice test, plan to spend about a minute on each question. Some questions you will answer quickly; others may take some time. Do not spend more than 2 minutes deliberating the answer to a ques- tion. If you do not have a good direction for the right answer in 2 minutes, then you probably don’t know the answer. Eliminate all of the options you can, pick the best one, and move on. (Remember, you are not sup- posed to know all of the right answers.) Plan for an hour of practice testing, select 60 questions, and answer the questions using testing strategies. After answering the questions, review the correct answers and focus on what and why you missed questions. Practice your timing and application of test strategies so you will be comfort- able with timing and the progression of questions on the NCLEX.
- The NCLEX is a nursing competency examination, and the correct answer will focus on nursing knowledge and the provision of nursing care. The examination does not focus on medical management or making a medical diagnosis.
- Eliminate distracters that include the assumption that the client would not understand or would be ignorant of the situation and those distracters that protect clients from worry. For example, “The client should not be told she has cancer because it would upset her too much” would almost certainly be an incorrect answer.
- There is no pattern of correct answers. The exam is compiled by a computer, and the position of the correct answers is selected at random. So, do not believe those who say to pick option 3 when you are guessing.
STUDY HABITS
Study Effectively
- Use memory aids, mind mapping, and mnemonics. Memory aids and mind mapping are tools that assist you in drawing associations from other ideas with the use of visual images (Figure l-13). Mnemonics are words, phrases, or other techniques that help you remember information. Images, pictures, and mnemonics will stay with you longer than written text information.
- Develop 3 × 5 cards with critical information. Do not overload the card; put a statement or question on one side and answers or follow-up information on the other side. For example, on one side you might write “low potassium,” and on the other side you would list the relevant values. Another card might say “nursing care for hypokalemia” on the front, and on the back, you could
going to be all right,” or “your doctor knows best” will be wrong answers.
- Look for responses that indicate an acceptance of the client. Regardless of whether the client’s views or moral values are in agreement with yours, it is important to respect his or her views and beliefs. Responses that involve telling clients what they should or should no t be doing are often wrong answers (e.g., telling an alcoholic that she should quit drinking or telling a depressed client that he should not feel that way).
- Be careful about responses that give opinions or advice on the client’s situation. Do not assume an authoritarian position. You should not insist that the client follow your advice (e.g., quit drinking, exercise more, quit smoking).
- Do not select options or responses that block further interaction. These options are frequently presented as closed statements or questions that encourage a yes-or-no answer from the client. Better responses are those that indicate an expectation of a more revealing verbal response from the client. Examples: “Are you feeling better today?” The client can just answer no to this question. It is better to ask, “How are you feeling today as compared to yes- terday?” Likewise, it is better to ask, “How did you feel when your family visited today?” rather than “Did your family visit today?”
- Look for responses that reflect, restate, or paraphrase feelings the client expressed. Look for responses that encourage the client to describe how he or she feels— responses that reflect, restate, or paraphrase feelings the client expresses. An option such as “You should not feel that way” is bound to be a wrong answer. It is better to ask, “How did that make you feel?”
- Do not ask “why” a client feels the way he or she does. Most of the time, if a client understood why he or she felt a certain way, the client would be able to do some- thing about it. The most common answer when a nurse asks a client why he or she feels a certain way is “I don’t know,” which does not help anyone.
- Do not use coercion to achieve a desired response. Do not tell clients that they can’t have their lunch until they get out of bed or bribe children to take their medicine with a promise of candy.
- See examples of therapeutic and nontherapeutic com- munication in Chapter 9 (Table 9-3).
TIPS FOR TEST-TAKING SUCCESS
- Do not indiscriminately change answers. On a paper- and-pencil test, if you go back and change an answer, you should have a specific reason for doing so. Sometimes you do remember information and realize you answered the question incorrectly. However, students often “talk themselves out” of the correct answer and change it to the incorrect one. The good news is that you cannot go back to previously answered questions on the NCLEX. At the point at which the examination asks you to confirm your answer, review the strategies used to answer
- Set a schedule and let everyone know the schedule. For example, when you set aside 1 hour for review on the day after your class, make sure everyone knows this is your study time. Do not expect your family to leave you alone while you study; this is frequently too much to ask, especially of children or a spouse. Go to the library, nursing school, or someone’s house where there are no disturbances.
- Start planning your NCLEX preparation at the begin- ning of your last semester in school or 2 to 3 months before you will take the NCLEX. Do not wait until the week before the exam to start preparing. Even if you were an A student, you still need to review. Information that was presented at the beginning of school, last year, or even last semester may not be current in your knowledge base.
Set a Study Goal
- Decide on a study method.
- Divide the review material into segments.
- Prioritize the segments; review first the areas in which you feel you are deficient or weak. Leave those areas you are the most comfortable with and most knowledgeable about for last.
- Practice testing, or an end of the semester assessment examination, will help you to identify areas in which you need additional review. Review this information in an NCLEX Review book, and then if it is not clear or if you need further explanation and information, consult your nursing textbooks.
- Establish a realistic schedule and follow it. Planning for 8 hours of studying on your day off does not work. Instead, plan for 2 to 4 hours each day (in 20- to 30-minute chunks of time) and maybe 3 to 4 hours
list the nursing care. These cards are much easier for you to carry than a load of books or class notes. When you have developed and studied your set of cards with priority information, trade them with friends, and see what they have put on their cards. Sets of cards can be used when- ever you have only 15 to 20 minutes of study time. Take 20 cards with you to soccer practice, the doctor’s office, or anywhere you are going where you will to have to sit and wait for a few minutes. This is quick, easy, and very effective.
- Review class notes the next day. A very effective study habit to develop during school is to review your class notes the day after the class. Set aside about an hour on the day after the class and spend about 30 to 45 minutes reviewing the notes from class. Do the notes make sense to you, or are you unclear on the meaning of some of the areas? Correlate the notes and the visuals the instructor presented with the information in the textbook. It is important to take the time now to understand the infor- mation presented the previous day because it is fresher in your mind and you are more receptive to learning. By reviewing the information after the class presentation, you more effectively and positively reinforce the learning process.
- Plan your study time when you are most receptive to learning. Do not wait until the end of the day when you have finished everything else. It is difficult to get up at 6:00 AM, work all day, deal with family activities, and finally realize at 10:30 PM that you are just too tired to study. You may feel guilty that you were not able to study for the intended 2 hours that evening. Schedule your study time—it may be easier for you to study for 2 hours before leaving school than it may be to study for 2 hours when you get home.
FIGURE 1-13 Peritonitis: “Hot Belly.” (From Zerwekh J, Claborn J: Memory notebook of nursing, vol 1, ed 4, Ingram, Texas, 2008, Nursing Education Consultants.)
