nclex®-pn tips

NCLEX®-PN TIPS
Targeted Instruction and Passing Strategies
NCLEX-PN® TIPS
Editor
Virtual and Distant Education Teams
Associate Editor
Brant Stacy, BS Journalism, BA English
Product Developer
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2011. NCLEX-PN® is a registered trademark of the National Council of State Boards of Nursing, Inc. and, as such,
use of the trademark is not considered an endorsement of this book.
NCLEX-PN TIPS
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Table of Contents
Unit 1 NCLEX-PN® Overview
Test Strategies and Essentials.......................................................................................................................3
Unit 2 2011 NCLEX-PN Detailed Test Plan
Safe and Effective Care Environment..........................................................................................................5
Health Promotion and Maintenance ..........................................................................................................6
Psychosocial Integrity.................................................................................................................................7
Physiological Integrity................................................................................................................................7
Unit 3 Understanding the NCLEX-PN Test Plan
Types of Exam Items.................................................................................................................................10
Common Pitfalls and Relevant Information..............................................................................................11
Summary...................................................................................................................................................14
Unit 4 Application of Knowledge
Staying Focused.........................................................................................................................................15
Managing Test Items.................................................................................................................................15
Strategies...................................................................................................................................................15
Essential NCLEX-PN Knowledge................................................................................................................17
Unit 5 Mastering Difficult Questions
Examine Question Layers..........................................................................................................................19
Airway, Breathing, and Circulation (ABC).................................................................................................20
Safe and Effective Delegation....................................................................................................................21
Conclusion
NCLEX-PN® Overview
UNIT 1
NCLEX-PN® OVERVIEW
Sections
Test Strategies and Essentials
Overview
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Now that you’ve graduated and worked hard preparing for a career in nursing, the time has come to take the
NCLEX-PN. You may be asking yourself:
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“I’ve prepared for so long, now what?”
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“Am I really ready to take the test?”
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“How can I be assured of a strong finish in this final stretch?”
You’ve learned the bulk of your knowledge in your nursing program, and your instructors have given you a lot of
useful information. Now, the National Council Licensure Exam (NCLEX-PN®) will ask you to demonstrate how well
you understand that knowledge and how well you can apply it to situations you may encounter in your nursing
career. This document will offer several strategies that you can use to increase your chances of passing the
NCLEX-PN.
Test Strategies and Essentials
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To become a licensed nurse in the United States or its territories, you must pass the NCLEX-PN exam. Preparation
for the NCLEX-PN should include familiarizing yourself with the construction and administration of the exam.
The National Council of State Boards of Nursing (NCSBN) prepares the NCLEX-PN exam. The exam is the same
regardless of the state or territory where you test. However, the requirement for receiving authorization to test does
vary from state to state. To find specific requirements for your state or territory, go to www.ncsbn.org and click
on the “Boards of Nursing” tab. To find testing centers in your state, go to www.pearsonvue.com/NCLEX. Some
states have compacts that allow mobility of their licensure status, which means if you are licensed to practice within
a particular state, other states may offer reciprocity that allows you to practice in those states as well. You can find
information about state compacts on the NCSBN website www.ncsbn.org/nlc.htm.
You may wonder why you have to take the NCLEX-PN licensure exam. The NCSBN wants to ensure that our
society has safe and effective nursing care. The licensure exam is a means of providing professional regulation for
competence at the entry level and helps to ensure public safety.
It is important to understand that the NCLEX-PN is not a test of intelligence. It is not a test for nurses who have
practice experience to show their level of achievement. It does not ask questions about highly specialized nursing
practices, cutting-edge technologies, vendor-specific equipment, or medication therapies not approved by the U.S.
Food and Drug Administration. The NCSBN uses specific criteria to ensure fairness, thus the exam must be:
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Psychometrically sound.
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Legally defensible.
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Objective.
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Empirical.
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Reliable.
To identify the current nature of entry-level professional practice, NCSBN conducts a practice analysis study every
3 years. Using the data, the NCSBN determines the competency level that nurses need to deliver safe and effective
care. The questions you’ll encounter on the NCLEX-PN are consistent with what entry-level nurses actually do in
clinical practice.
NCLEX-PN TIPS
3
NCLEX-PN® Overview
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The NCLEX-PN exam uses a computer-adaptive testing approach. This means the computer will determine
the level of difficulty for questions based on how you answered previous ones. So remember, every exam
will be different. But, every test-taker begins with relatively easy questions. Each time you answer a question,
the computer technology estimates your ability within the client-need categories. With every answer, the
computer’s estimate of your knowledge level gets more precise. If all goes well, you’ll reach a certain point in
the testing process where you demonstrate a minimal competency. This occurs when you answer questions
of a certain difficulty, and not after you answer a certain percentage of items. At this point, the computer
compares your ability level with the national passing mark. One of three outcomes will occur.
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If you are above the passing standard at question 85, your exam will end and you will pass.
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If you are below the passing standard at question 85, your exam will end and you will fail.
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If your ability estimate is close to the passing mark, either nearly below or nearly above, then you will
continue to receive more questions until a more precise judgment can be made about your knowledge
of the content on the exam. You will either pass or fail depending on your performance to that point.
You won’t pass if you score at the passing mark. You will need to achieve above it to receive a nursing
license.
Below are other important facts about the NCLEX-PN exam.
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The exam includes a minimum of 85 questions and a maximum of 205.
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The maximum time allowed is 5 hr.
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There is an optional 10-min break after the first 2 hr. There is a second optional 10-min break after 3.5
hr.
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Every test-taker receives 25 experimental questions.
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You will not be able to identify which items are experimental.
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Answers to experimental questions do not count in your score.
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NCLEX-PN TIPS
The full 205-question set is never randomly administered. The test will end when you demonstrate a
minimal competency (anywhere from 85 to 205 questions).
4
2011 NCLEX-PN® Detailed Test Plan
UNIT 2
2011 NCLEX-PN® DETAILED TEST PLAN
Sections
Safe and Effective Care Environment
Health Promotion and Maintenance
Psychosocial Integrity
Physiological Integrity
Overview
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On April 1, 2011, the NCSBN implemented a new test plan and a revised passing standard. To help determine
the passing standard, the NCSBN conducted a practice analysis study to determine the minimum amount of
knowledge, skills, and ability required for safe and effective entry-level nursing.
The distribution of test items in the NCLEX-PN Detailed Test Plan reflects the emphasis areas from the practice
analysis study. Below are the activity statements from the 2009 PN Practice Analysis of Newly Licensed PNs in
the United States and Member Board Jurisdictions, which are in the 2011 NCLEX-PN test plan. Each client-need
category and subcategory lists topic areas, while the percentages demonstrate the distribution for each category
within the test as a whole. As you prepare for the NCLEX-PN, familiarize yourself with the emphasis areas in the
current test plan. Also, note the difference between the previous plan (published in 2008). This will help you focus
your study efforts.
SAFE AND EFFECTIVE CARE ENVIRONMENT
Management of Care (13% to 19%)
Definition:
Topic areas –
related topics
include, but
not limited to:
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NCLEX-PN TIPS
The LPN/VN collaborates with the health care team members to facilitate effective client care.
Provide information about advance directives.
Advocate for client rights and needs.
Promote client self-advocacy.
Assign client care and/or related tasks (assistive personnel or LPN/VN).
Involve client in decision making.
Contribute to the development and/or update of the client plan of care.
Participate as a member of an interdisciplinary team.
Recognize and report staff conflict.
Participate in staff education.
Use data from various sources in making clinical decisions.
Supervise/evaluate activities of assistive personnel.
Maintain client confidentiality.
Provide for privacy needs.
Follow up with client after discharge.
Participate in client discharge or transfer.
Provide and receive report.
Organize and prioritize care for assigned group of clients.
Participate in client consent process.
Use information technology in client care.
Receive and process health care provider orders.
Recognize task/assignment you are not prepared to perform and seek assistance.
Respond to the unsafe practice of a health care provider (intervene or report).
Follow regulation/policy for reporting specific issues (abuse, neglect, gunshot wound, or communicable
disease).
Participate in quality improvement (QI) activity (collecting data or serving on QI committee).
Apply evidence-based practice when providing care.
Participate in client data collection and referral.
Participate in providing cost-effective care.
Integrate advance directives into the client’s plan of care.
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2011 NCLEX-PN® Detailed Test Plan
SAFE AND EFFECTIVE CARE ENVIRONMENT
Safety and Infection Control (11% to 17%)
Definition:
Topic areas
– related
topics include,
but not
limited to:
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The LPN/VN contributes to the protection of clients and health care personnel from health and environmental
hazards.
Identify client allergies and intervene as appropriate.
Verify the identity of a client.
Assist in or reinforce education to client about safety precautions.
Evaluate the appropriateness of health care provider order for client.
Participate in preparation for internal and external disasters (fire, natural disaster).
Use safe client handling (body mechanics).
Identify and address hazardous conditions in health care environment (chemical, smoking, or biohazard).
Acknowledge and document practice error (incident report).
Follow protocol for timed client monitoring (restraint, safety checks).
Implement least restrictive restraints or seclusion.
Assure availability and safe functioning of client-care equipment.
Initiate and participate in security alert (infant abduction, flight risk).
Identify the need for and implement appropriate isolation techniques.
Use standard/universal precautions.
Use aseptic and sterile techniques.
HEALTH PROMOTION AND MAINTENANCE (7% TO 13%)
Definition:
Topic areas
– related
topics include,
but not
limited to:
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NCLEX-PN TIPS
The LPN/VN provides nursing care for clients that incorporates knowledge of expected stages of growth and
development and prevention and/or early detection of health problems.
Provide care that meets the special needs of the newborn: less than 1 month old.
Provide care that meets the special needs of infants or children 1 month to 12 years.
Provide care that meets the special needs of adolescents 13 to 18 years.
Provide care that meets the special needs of young adults 19 to 30 years.
Provide care that meets the special needs of adults 31 to 64 years.
Provide care that meets the special needs of adults 65 to 85 years.
Provide care that meets the special needs of adults greater than 85 years.
Assist with fetal heart monitoring for the antepartum client.
Assist with monitoring a client in labor.
Monitor recovery of stable postpartum client.
Collect data for health history.
Collect baseline physical data (skin integrity, height and weight).
Recognize barriers to communication or learning.
Compare client development to norms.
Assist client with expected life transition (attachment to newborn, parenting, retirement).
Provide care and resources for beginning-of-life and/or end-of-life issues and choices.
Identify and educate clients in need of immunizations (required and voluntary).
Participate in health screening or promotion programs.
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2011 NCLEX-PN® Detailed Test Plan
PSYCHOSOCIAL INTEGRITY (7% TO 13%)
Definition:
Topic areas
– related
topics include,
but not
limited to:
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The LPN/VN provides care that assists with promotion and support of the emotional, mental, and social wellbeing of clients.
Assist in or reinforce education to caregivers/family on ways to manage client with behavioral disorders.
Participate in behavior management program by recognizing environmental stressors and/or providing a
therapeutic environment.
Participate in reminiscence or validation therapy, or reality orientation.
Participate in client-group session.
Identify signs and symptoms of substance abuse/chemical dependency, withdrawal, or toxicity.
Collect data regarding client psychosocial functioning.
Identify client use of effective and ineffective coping mechanisms.
Identify significant body or lifestyle changes and other stressors that may affect recovery/health maintenance.
Assist client to cope/adapt to stressful events and changes in health status (end of life, grief and loss, life
changes, or physical changes).
Collect data on client who has potential to be violent.
Assist in managing the care of the client who is angry/agitated.
Make adjustment to care with consideration of a client’s spiritual or cultural beliefs.
Explore why client is refusing or not following treatment plan.
Assist in the care of the client who is cognitively impaired.
Promote positive self-esteem of client.
Provide emotional support to client and family.
PHYSIOLOGICAL INTEGRITY
Basic Care and Comfort (9% to 15%)
Definition:
Topic areas
– related
topics include,
but not
limited to:
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NCLEX-PN TIPS
The LPN/VN provides comfort to clients, and assists them in the performance of their activities of daily living.
Use transfer assistive devices (t-belt, slide board, mechanical lift).
Institute bowel or bladder management.
Discontinue or remove peripheral IV line, NG tube, or urinary catheter.
Perform an irrigation of urinary catheter, bladder, wound, ear, nose, or eye.
Provide for mobility needs (ambulation, range of motion, transfer to chair, repositioning, the use of adaptive
equipment).
Use measures to maintain or improve client skin integrity.
Provide care to client in traction.
Apply or remove immobilizing equipment (a splint or brace).
Assist in the care and comfort for a client with a visual and/or hearing impairment.
Use alternative/complementary therapy (acupressure, music therapy, herbal therapy) in providing client care.
Provide nonpharmacological measures for pain relief (imagery, massage, repositioning).
Evaluate pain using a rating scale.
Provide feeding and/or care for client with enteral tubes.
Monitor and provide for nutritional needs of client (laboratory findings, calorie counts/percentages, daily
weight).
Monitor client I&O.
Assist with activities of daily living.
Assist in providing postmortem care.
Provide measures to promote sleep/rest.
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2011 NCLEX-PN® Detailed Test Plan
PHYSIOLOGICAL INTEGRITY
Pharmacological and Parenteral Therapies (11% to 17%)
Definition:
Topic Areas
– related
topics include,
but not
limited to:
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The LPN/VN provides care related to the administration of medications and monitors clients receiving
parenteral therapies.
Perform calculations for medication administration.
Reinforce education to client regarding medications.
Evaluate client response to medication.
Follow the rights of medication administration.
Maintain medication safety practices (storage, checking for expiration dates, compatibility).
Reconcile and maintain medication list or medication administration record.
Administer medication by oral route.
Administer IV piggyback (secondary) medications.
Administer medication by gastrointestinal tube (g-tube, NG tube, g-button, or j-tube).
Administer a subcutaneous, intradermal or intramuscular medication.
Administer medication by ear, eye, nose, rectum, vagina, or skin.
Count narcotics/controlled substances.
Regulate client IV rate.
Monitor transfusion of blood product.
Monitor and maintain client IV site and flow rate.
Risk Potential (9% to 15%)
Definition:
Topic Areas
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topics include,
but not
limited to:
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NCLEX-PN TIPS
The LPN/VN reduces the potential for clients to develop complications or health problems related to
treatments, procedures, or existing conditions.
Check and monitor client vital signs.
Perform an electrocardiogram (ECG).
Perform venipuncture for blood draws.
Collect specimen (urine, stool, gastric contents, or sputum for diagnostic testing).
Monitor diagnostic or laboratory test results.
Identify signs or symptoms of potential prenatal complication.
Perform neurological checks.
Perform circulatory checks.
Check for urinary retention (bladder scan, palpation).
Administer and check proper use of compression stockings/sequential compression devices.
Perform risk monitoring and provide follow up.
Monitor continuous or intermittent suction of NG tube.
Implement measures to prevent complication of client condition or procedure (circulatory complication,
seizure, aspiration, or potential neurological disorder).
Evaluate client respiratory status by measuring oxygen (O2) saturation.
Provide care for client before surgical procedure including teaching.
Insert urinary catheter.
Insert NG tube.
Assist with the performance of a diagnostic or invasive procedure.
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2011 NCLEX-PN® Detailed Test Plan
PHYSIOLOGICAL INTEGRITY
Physiological Adaptation (9% to 15%)
Definition:
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Topic areas
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topics include,
but not
limited to:
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The LPN/VN participates in providing care for clients with acute, chronic, or life-threatening physical health
conditions.
Assist with invasive procedures (central-line placement).
Implement and monitor phototherapy.
Maintain the desired temperature of a client (cooling and/or warming blanket).
Monitor and care for clients who are receiving ventilation.
Monitor and maintain devices and equipment for drainage (surgical wound drains, chest-tube suction, negative
pressure, wound therapy).
Perform and manage care of a client who is receiving peritoneal dialysis.
Perform suctioning (oral, nasopharyngeal, endotracheal, tracheal).
Provide wound care and/or assist with dressing change.
Provide ostomy care and education (tracheal, enteral).
Provide pulmonary hygiene (chest physiotherapy, incentive spirometry).
Provide postoperative care.
Manage the care of the client who has fluid and electrolyte imbalance.
Monitor and maintain arterial lines.
Manage the care of a client who has a pacing device (pacemaker, biventricular pacemaker, implantable
cardioverter defibrillator).
Manage the care of the client who is on telemetry.
Manage the care of a client who is receiving hemodialysis.
Manage the care of a client who has alteration in hemodynamics, tissue perfusion, and hemostasis (cerebral,
cardiac, peripheral).
Manage the care of a client who has impaired ventilation/oxygenation.
Evaluate the effectiveness of the treatment regimen for a client who has an acute or chronic diagnosis.
Perform emergency care procedures (CPR, abdominal thrust maneuver, respiratory support, automated
external defibrillator).
Identify pathophysiology related to an acute or chronic condition (signs and symptoms).
When providing client care, recognize signs and symptoms of complications and intervene appropriately.
Application and analysis items primarily compose the NCLEX-PN. However, there are some lower-level knowledge
and comprehension items. Be sure you have a broad knowledge in all client-need categories. This will help you
demonstrate a minimal level of competency when you need to apply your knowledge to the scenarios on the exam.
NCLEX-PN TIPS
9
Understanding the NCLEX-PN® Test Plan
UNIT 3
UNDERSTANDING THE NCLEX-PN® TEST PLAN
Sections
Types of Exam Items, Common Pitfalls and Relevant Information, Summary
Overview
You will learn how to determine what information needs addressing by eliminating information that is irrelevant.
This process clears a pathway to the correct answer. It also helps you answer quite a few of the most difficult
questions correctly, which will lead to a passing score on the exam.
Types of Exam Items
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The NCLEX-PN examination is a different type of testing experience than taking a unit exam in nursing school.
All test items follow Bloom’s Taxonomy (Bloom, et al, 1956), which is the progressive hierarchy for classifying a
person’s thinking skills. Most items are at the application and analysis levels of the taxonomy. The highest two
levels are synthesis and evaluation, which are present, but less common with standard four-option multiple-choice
questions.
Even though you won’t see many knowledge or comprehension questions on the NCLEX-PN, you should be able
to identify them as you prepare for your exam. Then, you won’t spend too much of your study time on these
questions. And, there won’t be any surprises on test day.
Knowledge questions test recall and recognition. Consider the examples below (correct answers are in bold).
A client has an enteral feeding tube inserted for nutritional supplementation. Before administering the first bolus feeding, how
should the nurse verify proper placement of the tube?
A. Check for residual gastric contents.
B. Obtain an x-ray to confirm tube placement.
C. Inject air into the tube while listening over the epigastrium.
D. Confirm that the pH of the gastric aspirate is less than 4.0.
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Comprehension questions test the ability to translate and interpret.
Prior to administering morning medications to a client, a nurse notes the activated partial thromboplastin time (aPTT) is 110
seconds. Which of the following actions should the nurse take first?
A. Hold the scheduled dose of heparin.
B. Administer the medications, as prescribed.
C. Compare the finding to the previous aPTT level.
D. Ask the laboratory to repeat the test for verification.
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Remember, you will see a lot of application and analysis level questions on the NCLEX-PN. These questions require
you to use your knowledge to solve client problems. You need to decide what is most important in the context of
multiple client conditions. Before attempting to choose an answer, you should consciously identify key words in
the stem that are relevant and dismiss irrelevant information.
NCLEX-PN TIPS
10
Understanding the NCLEX-PN® Test Plan
Common Pitfalls and Relevant Information
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Graduate nurses commonly choose answers that relate to what is being asked rather than answer what is being
asked.
A nurse is standing at the bedside of a client when the monitor pattern changes and appears to show ventricular fibrillation.
Which of the following actions should the nurse take first?
A. Defibrillate the client.
B. Start rescue breathing.
C. Print a copy of the rhythm.
D. Palpate the client’s carotid pulse.
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The question assumes that you’re knowledgeable about ventricular fibrillation, which is always a pulseless rhythm.
You should also know that you treat ventricular fibrillation by performing defibrillation.
What is the question asking?
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What is the treatment for ventricular fibrillation? No!
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What is the priority nursing action when you suspect ventricular fibrillation? Yes!
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The word “appears” changes what the question is asking. You should recognize that although the monitor
shows ventricular fibrillation, you shouldn’t initiate a rescue intervention until you establish absence of a
pulse. Therefore, D is the correct option.
Although you may have the knowledge to answer the question correctly, you must also be careful to
choose the correct order of interventions. You can accomplish this by giving key words in the stem
appropriate attention. If you don’t do this, you may choose an answer to a question that was not asked.
What information is relevant?
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Examine the examples below and practice identifying issues that are important or irrelevant to what is being
asked.
A nurse is caring for a client who is obese and has a history of type 1 diabetes mellitus. The client is also 1 week postoperative
following a ventral hernia repair. He reports severe abdominal pain 1 hr after vomiting. Which of the following actions should
the nurse take?
A. Perform a fingerstick blood glucose test.
B. Ask the RN to administer IV pain medication.
C. Remove the dressing and observe the incision line.
D. Reinforce information on pillow splinting and repositioning.
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What factor(s) are relevant in the question?
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Client is obese
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Client underwent abdominal surgery 1 week ago
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Client is experiencing severe abdominal pain
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Client vomited 1 hr ago
What factor(s) should be dismissed?
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The client has a history of type 1 diabetes mellitus
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The client has a ventral hernia repair
What is the question asking?
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NCLEX-PN TIPS
The question is asking for the priority nursing action for a client who has had abdominal surgery and vomited
1 hr ago. Option C is correct because the nurse should assess the incision for wound dehiscence.
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Understanding the NCLEX-PN® Test Plan
A nurse is caring for a client who sustained multiple rib fractures and severe facial trauma during a motor-vehicle crash. Which of
the following findings should concern the nurse most?
A. Increasing lethargy
B. Shallow respirations
C. Chest pain with positioning
D. Bloody drainage from the nose
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What factor(s) are relevant in the question?
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What factor(s) should be dismissed?
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Client has multiple skeletal fractures
Client has severe facial trauma
What is this question asking?
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The question is asking for the most clinically significant assessment data for a client who sustained multiple
skeletal fractures. Option A is correct because development of a fat embolus can cause disorientation or other
CNS involvement.
A client reports recurring calf pain that occurs with walking. The nurse notes that the client has weak pedal pulses and the skin
on her lower legs is shiny, pale, and cool to touch. Which of the following instructions should the nurse reinforce?
A. “You will need to stop all activity that causes this pain.”
B. “Elevate your legs several times a day to improve circulation.”
C. “We will need to immobilize your legs pending further evaluation.”
D. “Sit down and put your legs in a dependent position when this occurs.”
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What factor(s) are relevant in the question?
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Recurring calf pain with activity
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Onset of calf pain after a short distance
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Feet that are shiny, pale, and cool
What is the question asking?
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The question is asking for the most appropriate intervention for a client who has peripheral arterial disease.
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Option D is correct because placing the leg in a dependent position will increase blood flow to the extremity.
A client who is semicomatose and has an NG tube set to low-intermittent suction is starting total parenteral nutrition. Which of
the following actions is most appropriate for the nurse to take to prevent fluid volume deficit?
A. Increase oral fluid intake to 3 L/day.
B. Determine the client’s fluid intake every 8 hr.
C. Monitor serum glucose levels and administer insulin.
D. Check residuals and give boluses of water through the NG tube.
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What factor(s) are relevant in the question?
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Administration of total parenteral nutrition
What factor(s) should be dismissed?
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Client is semicomatose
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NG tube set to low-intermittent suction
What is the question asking?
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NCLEX-PN TIPS
The question is asking for the intervention that is most important to prevent the development of fluid volume
deficit in a client who is starting total parenteral nutrition. Option C is correct because timely blood glucose
monitoring will alert the nurse to hyperglycemia, which can induce osmotic diuresis.
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Understanding the NCLEX-PN® Test Plan
A nurse is preparing to discharge an adolescent who is primapara 12 hr after vaginal delivery of a term newborn. A follow-up
home visit is scheduled for 24 hr after discharge. Which of the following is most important for the nurse to include in the client’s
discharge teaching?
A. Demonstrate postpartum self-care skills.
B. Discuss psychological responses to childbirth.
C. Review physiological changes after childbirth.
D. Explain nutritional approaches for weight loss.
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What factor(s) are relevant in the question?
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Client is primipara
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Client is discharged after 12 hr
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Client’s first home visit is in 24 hr
What factor(s) should be dismissed?
◯◯
Newborn born at term
◯◯
Client is an adolescent
What is the question asking?
◯◯
The question is asking for the most important content to teach prior to discharging a client who is primipara.
So, option A is correct. Since a home visit is scheduled in 24 hr, the nurse’s priority needs to be education that
promotes comfort, rest, and prevention of complications.
A client diagnosed with depression related to marital conflict asks the nurse, “Do you think I should divorce my spouse or just
separate?” Which of the following responses by the nurse is most appropriate?
A. “What do you think is the best thing for you to do at this point?”
B. “If you do divorce, do you have sufficient income to support yourself?”
C. “How do you think divorce will affect your children now and in the future?”
D. “You should divorce, since marital conflict is the source of your depression.”
●●
What factor(s) are relevant in the question?
◯◯
●●
What factor(s) should be dismissed?
◯◯
●●
Client is depressed
The topic of the client’s decision
What is the question asking?
◯◯
NCLEX-PN TIPS
The question is asking for a therapeutic response to a client with depression. Option A is correct, because a
statement that is open-ended and information-seeking is most appropriate.
13
Understanding the NCLEX-PN® Test Plan
A school nurse observes several children playing on the playground at a local elementary school. Which of the following children
requires immediate intervention by the nurse?
A. A child climbing on the swing-set
B. Two children arguing with each other
C. A child breathing heavily after running
D. A child squatting after playing catch with a ball
●●
●●
●●
What factor(s) are relevant in the question?
◯◯
Children are school age
◯◯
Children are playing
What factor(s) should be dismissed?
◯◯
The location of the school
◯◯
Where the children are playing
What is the question asking?
◯◯
The question is asking to identify the child that is demonstrating postplay behavior that may indicate distress
or injury. Option D is correct because a squatting stance after activity is a clinical manifestation of cyanotic
heart disease.
Summary
●●
Now you should understand Bloom’s taxonomy and practice questions written at the application and analysis level.
As you move toward succeeding on the NCLEX-PN, “answering what is being asked” is the starting point to getting
the questions right. Eliminating irrelevant information will help you identify the issues of importance, which will
guide you to the correct answer. Practice this strategy while taking each of the ATI practice assessments. Read each
question carefully and purposely dismiss irrelevant content in the stem. Draw your attention to the relevant details
as you consider and eliminate possible answer choices.
NCLEX-PN TIPS
14
Application of Knowledge
UNIT 4
APPLICATION OF KNOWLEDGE
Sections
Staying Focused, Managing Test Items, Strategies, Essential NCLEX-PN Knowledge
Overview
●●
Now that you know how to determine what the question is asking, you should turn your energy toward “using
what you know.” The following strategies will teach you to choose answers wisely, even if you are doubtful about
your knowledge of the topic. They will help you to stay in control of the test, minimize guessing, and reduce
anxiety.
Staying Focused
●●
●●
●●
Graduate nurses taking the NCLEX tend to focus on what they don’t know, rather than what they do know. The
ramifications of this mental approach can be devastating.
When you focus on your lack of knowledge about a particular topic, you may become anxious and start guessing
or changing answers. There is also a carryover effect that can reduce your ability to answer subsequent items. You
might start losing confidence. When that happens, the test begins controlling you. You need to pause, take a deep
breath, try to relax, and move on. Remember, keep your focus.
One of the most important factors in achieving success on the NCLEX is maintaining control of the test. This comes
from understanding the construction of the test and its administration, as well as systematically managing its
items.
Managing Test Items
●●
How should you manage an item when you don’t think you know anything about the topic? It’s natural to become
anxious if you don’t remember much about the topic; however, don’t panic. Use your “default testing strategy.”
Default strategies promote “using what you know.” This puts you back in the driver’s seat and keeps you in control
of the test. The next section describes three important strategies.
Strategies
●●
Use time to your advantage.
◯◯
◯◯
◯◯
●●
Early vs. late. What do you know about questions asking you to identify early and late signs and symptoms?
You should know they all have something in common. Early clinical manifestations are general and
nonspecific, whereas late signs are specific and serious. Eliminate incorrect answer choices using this strategy.
Pre, post, and intra. The test may ask you questions about complications that are pertinent to certain
procedures. What should you do if you know little or nothing about the procedure? Pay attention to whether
the question is asking about “preprocedural,” “intraprocedural,” or “postprocedural” concerns. Eliminate the
options that do not correspond to what the question is asking. The correct answer may be quite obvious when
viewing the question from this perspective.
Time elapsed. The priority nursing action will change depending on the time interval stipulated. Obviously, the
closer the client is to the origination of risk, the higher the risk for complications. Sometimes, the time issue
is in terms of hours or days. In other instances, the physical location of the client will tell you how long it has
been since the origination of risk. Watch closely for whether the client is in the “recovery room,” “postsurgical
unit,” or somewhere else. The time issue in those words will help you eliminate incorrect answers that don’t
match what the question is asking.
Let Maslow’s hierarchy of needs be your guide.
◯◯
NCLEX-PN TIPS
When taking the NCLEX, keep in mind that physiological safety will always be more important than anything
psychological. You can eliminate answers on the premise that you must establish physiologic safety prior
to initiating therapeutic psychologic nursing actions. If you lack knowledge about what do to in a certain
situation, let Maslow’s hierarchy guide you toward the correct answer. Remember, the hierarchy starts with
physiological needs and proceeds to safety and security, then love and belonging, self-esteem and, finally, selfactualization.
15
Application of Knowledge
●●
Remember: most complete = least room for error
◯◯
●●
You’ll encounter items on the NCLEX that will ask you to choose the instruction or documentation that is most
accurate. What should you do if you don’t remember much about the subject matter? Choosing an answer that
is most complete will typically result in the least room for error and subsequent delivery of safe and effective
care. To help you determine which answer is most complete, evaluate answers on how much objectivity (fact)
vs. subjectivity (opinion) there is in the answer choices. A specific value, like a blood pressure, is factual,
whereas a client’s report of past incidences of “high” blood pressure is subjective. Responses that are subjective
are generally not correct.
Additional default strategies
◯◯
◯◯
◯◯
◯◯
◯◯
◯◯
◯◯
You can usually discover the answer to a question by looking closely at the groupings of words or actions. Scan
the stem and the answer choices for cues. Identifying these cues often leads to a correlation that connects the
stem to a particular answer choice.
Read the question and options closely for words asking about direction or magnitude. For instance, stop and
concentrate on the terms intra vs. inter; hyper vs. hypo; increase vs. decrease; lesser vs. greater; and gain vs.
lose. It is common to misread these terms by simply skimming over them.
When in doubt, always choose a nursing action that could prevent harm to the client. Even if you don’t know
whether it relates to the stem, it is still a life-saving maneuver that, in all likelihood, is correct.
Rarely will a correct answer have the nurse physically leave the client. Choose an answer that keeps the nurse
with the client.
In some instances, rule out an option if you know it is associated with something else. For example, you may
not know about the laboratory values for warfarin therapy, but you do know the laboratory values for heparin
and aspirin. You can eliminate those values because you are “using what you know.”
Graduate nurses taking the NCLEX have a tendency to use the same communication skills regardless of
whether the client has anxiety, depression, schizophrenia, bipolar disorder or obsessive-compulsive disorder.
Everyone wants to be caring and use empathetic listening. Unfortunately, these are not therapeutic responses
for all disorders and every situation. Keep it very simple and apply it correctly. Again, use what you know.
Responses that are open-ended acknowledge the client’s feelings and seek more information. This approach is
appropriate for a client who has anxiety, a knowledge deficit, or depression.
◯◯
Reality orientation is important for a client with paranoia and delusions.
◯◯
Distraction is more appropriate for a client with obsessive-compulsive disorder.
◯◯
Use of the nursing process can be helpful. Always remember to “assess” first. Even if your knowledge of the
topic is gray, you can still recognize that an answer choice is an “assessment” rather than an “intervention.”
A nurse is caring for a client who is receiving isocarboxazid (Marplan). Which of the following prescriptions should the nurse
question?
A. Ibuprofen (Motrin)
B. Nifedipine (Procardia)
C. Acetaminophen (Tylenol)
D. Acetylsalicylic acid (Aspirin)
Default strategy: If you do not know much about isocarboxazid, choose the option that is most different from the
others. Acetaminophen is a medication associated with the development of antiplatelet antibodies, resulting in
thrombocytopenia. Aspirin and ibuprofen have NSAID properties that have antiplatelet aggregation properties. As these
three are somewhat similar, the correct answer is likely to be nifedipine.
NCLEX-PN TIPS
16
Application of Knowledge
A nurse is caring for an infant who is experiencing sickle-cell crisis and requires pain medication. Which of the following
medications should the nurse expect the infant to receive?
A. Acetylsalicylic acid (Aspirin)
B. Morphine sulfate (Morphine)
C. Meperidine hydrochloride (Demerol)
D. Acetaminophen with codeine (Tylenol #3)
Default strategy: If you do not know much about pain medication for infants, use what you do know. You probably
know that an infant can’t have aspirin-based and combination products because of the risk of Reye syndrome; therefore,
acetylsalicylic acid is incorrect. You can safely administer acetaminophen to children, and acetaminophen with codeine
also addresses severe pain. Meperidine hydrochloride causes metabolites to form in the CNS. And for an infant, morphine
is a powerful medication that may possibly be given after the acetaminophen with codeine. The best answer for this
question is D.
A nurse is caring for a client who has received 3 months of 5-fluorouracil (5-FU) therapy for the treatment of breast cancer. Which
of these findings should the nurse anticipate as an expected response to therapy? (Select all that apply.)
A. WBC count of 1,200 mm3
B. Weight gain of 2.27 kg (5 lb)
C. Blood pressure of 190/102 mm Hg
D. Urine-specific gravity of 1.043
E. Platelets of 5,000 mm3
Default strategy: Since this medication is a chemotherapy agent (which is immunosuppressive therapy), look for signs of
immunosuppression. This should lead you to the correct answer, which is A and E.
A client dies while her partner is standing at the bedside. What should the nurse do?
A. Give the partner time alone with the client.
B. Stay with the partner at the client’s bedside.
C. Ask the chaplain to come be with the partner.
D. Escort the partner to a private conference room.
Default strategy: Test-takers usually miss these common items. Graduate nurses think families want to be left alone to
grieve. Remember, the default strategy: Rarely will a correct answer have a nurse physically leave a client. Stay with your
client to provide support and comfort. The best response for this question is B.
Essential NCLEX-PN Knowledge
●●
Certain conditions may have more complex issues. So, there will be more representation of them on the test. As you
prepare for the NCLEX, take note of the list of topics. It is much easier to “use what you know” when you have the
appropriate knowledge going into the test.
◯◯
◯◯
Understand and differentiate normal laboratory values (serum sodium, potassium, calcium, creatinine,
magnesium, BUN, phosphorus, WBCs, platelets, ESR, Hct, Hgb, pH, PaCO2, SaO2)
Differentiate normal laboratory values to clinically significant client care issues vs. clinically insignificant or
clinically impossible scenarios
◯◯
Review drug categories
◯◯
Normal 24-hr intake and urine output
◯◯
Peritoneal dialysis
◯◯
Hemodialysis
◯◯
Complications (acute and chronic) of spinal cord transection: autonomic dysreflexia
◯◯
Complications of hepatic failure: hepatic encephalopathy
◯◯
Pregnancy-induced hypertension
◯◯
Premature rupture of membranes: clinical management
◯◯
Late decelerations: management
NCLEX-PN TIPS
17
Application of Knowledge
◯◯
Oxytocin (Pitocin) administration
◯◯
Sepsis: newborn and adult
◯◯
Meningitis
◯◯
Increased intracranial pressure: clinical manifestations
◯◯
All types of traction
◯◯
Compartment syndrome
◯◯
Pulmonary embolus
◯◯
Fat embolus
◯◯
Hemophilia (A)
◯◯
Sickle-cell crisis
◯◯
Gastric bypass: dumping syndrome
◯◯
Diets: diabetic, healthy heart, high fiber, renal, celiac, and regional enteritis
◯◯
Emergency burn care
◯◯
Procedures: nursing care (look for complications)
◯◯
Growth and development
NCLEX-PN TIPS
18
Mastering Difficult Questions
UNIT 5
MASTERING DIFFICULT QUESTIONS
Sections
Examine Question Layers, Airway, Breathing, and Circulation (ABC), Safe and Effective Delegation
Overview
●●
●●
●●
You know about the construction of the NCLEX exam, its administration, and general preparation techniques.
You also know how to “answer what is being asked” and strategies for answering items when you have little or
no knowledge about a topic. Now let’s focus on “getting the most difficult questions correct.” These questions
are known as “priority items.” These items will ask you to recognize life and death issues and execute the nursing
process in a fashion that provides clients with the highest level of safe and effective care.
Priority items don’t have a label on the test. And, there is no set coding of how these items appear on the test.
Instead, you must learn to identify how these items are written. Let’s discuss some of the textual formatting that
will help you recognize a priority item.
The table below lists statements commonly found in priority items. Note that many of them are asking you to
recognize issues of life and death, and to make decisions that will keep clients safe.
◯◯
Statements commonly found in priority items
■■
Who should the nurse see first?
■■
Which phone call should the nurse return first?
■■
Who should the nurse transfer first?
■■
Who should the nurse discharge first?
■■
Which option requires an immediate intervention?
■■
Which option requires no intervention?
■■
Which nursing action is most important?
■■
Which client should an LPN care for?
■■
Which client should a float nurse care for?
■■
Which assessment pattern is unexpected for this client?
■■
Which assessment pattern is expected for this client?
Examine Question Layers
●●
You may think that life and death issues are very easy to recognize in the text of a question. Unfortunately, they
are not always obvious. Instead, they are under words that, at first glance, seem to bear no clinical significance.
To prevent glancing over these words and missing the most critical or impending symptom, you will need to ask
yourself: “What could be the possible clinical significance of each answer choice?” Let’s look at a few items together
and practice this strategy.
NCLEX-PN TIPS
19
Mastering Difficult Questions
A nurse is caring for a client who has a cervical radium implant. Which of the following requires an immediate intervention by
the nurse?
A. The client is performing her own perineal care.
B. A staff member flushes the client’s urine down the toilet.
C. A staff member removes dirty linens from the client’s room.
D. The client is asking that visitors be restricted to immediate family.
●●
●●
●●
The first option doesn’t require immediate attention because the client has already been exposed to the sealed
radium implant. The client is able to perform her own perineal care. Health care providers should never be close
enough to do perineal care for a client who has a radium implant due to the risk of exposure.
If you aren’t careful, you could easily glance over it. To answer the question correctly, you need to consciously ask
yourself, “What is the potential safety risk of removing linen from this client’s room?” In other words, you need to
look beneath the words to find what may be a life and death issue.
If the radium implant displaces from the cervix into the bed linens and circulates within the central laundry supply,
everyone may be at risk for exposure. On the surface, the second option seems to contain a life and death layer, but
in reality, it is not an issue at all. Radium implants are sealed. So, there’s no contamination to the urine. Flushing
the urine down the toilet is safe and doesn’t require immediate attention. The fourth option is similar to the first in
that exposure to the radium implant is minimal for all people in the client’s immediate surroundings. This measure
provides safety and doesn’t require immediate attention. Therefore, C is correct. Never remove the bed linens until
you remove the radium implant from the client.
A nurse is caring for an adolescent who was admitted after an automobile crash. Which of the following should the nurse
consider as a priority assessment finding?
A. Unilateral pelvic bruising
B. Capillary refill 3 seconds
C. Hypoactive bowel sounds
D. Elevated blood pressure
●●
●●
●●
●●
The first option describes a condition that may be very serious. As you consider your options, remember to ask
yourself, “What is the clinical significance of the pelvic bruising?” If the trauma to the pelvis was significant enough
to cause bruising, it may have been significant enough to cause a pelvic fracture or bleeding in the abdominal cavity.
Therefore, A is correct. Abdominal bruising is an external finding indicating potential internal injury. The nurse
should assess for complications of pelvic and/or abdominal trauma.
In the second option, the capillary refill is normal. So, you shouldn’t investigate it first.
In the third option the client’s bowel sounds are hypoactive. On the surface, this finding may seem clinically
significant. But you should expect this since the client has undergone physiologic and psychologic stress. Don’t
investigate this first.
In the last option, the blood pressure is slightly elevated, which may seem clinically significant. But, don’t
investigate it first. A client admitted to the hospital following a car crash will likely be anxious and in pain. So, you
should expect slight elevations in blood pressure and respiratory rate.
Airway, Breathing, and Circulation (ABC)
●●
●●
●●
Priority items commonly address issues central to survival, specifically airway, breathing, and circulation (ABC).
They ask you to recognize and intervene to preserve the respiratory and cardiovascular systems. Failure to protect
these systems will lead to client deterioration and death.
As you answer priority items, you should consider each answer as it relates to protection of a client’s ABC. It is also
important to consider ABC checks with the perspective of trying to save a client’s life.
To avoid some common pitfalls when answering priority questions, be aware of the following:
◯◯
◯◯
NCLEX-PN TIPS
It is not unusual to want to care for a client who, in your mind, is the sickest. However, this may be an
inappropriate choice in triage situations. Clients who are so sick that you can’t save them shouldn’t receive
treatment first.
Many times you may feel empathy for innocent victims of injury and want to console them and check them
quickly before moving on to learned strategies. An example of this might be a rape victim or a child who
is a victim of neglect. Psychological issues are always secondary and never take priority over facilitation of
physiologic safety.
20
Mastering Difficult Questions
◯◯
◯◯
●●
Never perform ABC checks blindly without considering whether ABC issues are acute vs. chronic, or stable vs.
unstable. For example, a client who is quadriplegic and receiving ventilation has chronic airway/breathing
problems. However, if there is not an acute consideration, such as pneumonia, you should consider the client
chronic and stable. So, this should not be a nurse’s first priority.
You may want to answer questions on the way you saw procedures done while you were in a clinical setting at
school, during summer employment, or working as an intern. But remember, answers to NCLEX items must
be consistent with nationwide practice standards. So, they may not be the same as what you did within your
particular institution or geographic area.
Let’s take a look at the following question:
Four clients are brought to the emergency department following a work-site explosion. Which of the following clients should the
nurse triage first?
A. The client with a fractured hip who is reporting moderate hip pain
B. The client who is unresponsive, has dilated and fixed pupils, and has agonal respirations
C. The client with burns to the nose, mouth, and hands, and has minimal respiratory stridor
D. The client with type 2 diabetes mellitus and has tachycardia, slight hypotension, and tachypnea
●●
●●
●●
●●
The client in the first option has a fractured hip and moderate pain. The client is clearly acute, but stable, and you
can treat him at a later time. The client does not need to be seen first.
The client in the second option is unresponsive and has agonal respirations. The client is acute and unstable and
has pupils that are fixed and dilated. This indicates probable brain death. The client also has obvious breathing and
circulation issues. He is clearly the sickest; however, this client cannot be saved. Consequently, this client is not your
priority because it is unlikely that anything can be done to improve his clinical condition. This client does not need
to be seen first.
The client in the third option has burns to the face. Burns to the face, especially near the mouth and nose,
commonly result in damage to the airway. Here lies the life and death layer that you must acknowledge. This client
is acute and unstable. Although he has no obvious airway or breathing issues, there is a great risk. Early assessment
and intervention optimizes protection of the respiratory system. Therefore, you should care for this client first.
The client in the fourth option has slight hypotension and tachypnea, which indicates evolving diabetic
ketoacidosis. Tachypnea is compensatory and favorable for reduction of pH. The client’s blood pressure is dropping
because of the hyperglycemic-induced diuresis. Tachycardia is likely a compensatory phenomenon from the fluidvolume deficit. Breathing and circulation issues are present, but the client is technically acute and stable. So, he
should not be seen first.
Safe and Effective Delegation
●●
Safe and effective delegation of tasks and client-care assignments are extremely important when setting priorities for
client care. The rules below do not allow for opinion and preference. Follow them exactly so that the appropriate
health care personnel are performing activities that are safely within their scope of practice.
◯◯
◯◯
◯◯
◯◯
◯◯
◯◯
◯◯
NCLEX-PN TIPS
The delivery of safe and effective care is always the driving force behind delegation of tasks and client-care
assignments. Any other option will be incorrect.
RNs perform all client teaching. No matter how simple the teaching, it still must be done by the RN. The
licensed practical nurse (LPN) may reinforce teaching performed by the RN.
RNs should perform all admission assessments so that an accurate baseline is established. This includes the first
set of vital signs, all aspects of the first physical assessment, and a health history.
Client-care assignments are made by the RN, not by support staff. Client-care assignments should remain
unchanged unless there is an authentic issue of client-care safety or the safety of a health care provider is in
danger.
Assistive personnel (AP) can perform tasks such as taking vital signs, range-of-motion exercises, bathing, bed
making, obtaining urine specimens, enemas, and blood glucose monitoring. An AP cannot interpret results or
perform any task beyond the skill level of any certification already attained.
All communication between the RN and support staff should be direct, objective, and complete to ensure the
highest level of safe and effective care delivery.
An RN supervises and manages an LPN. RNs can delegate certain higher-level skills after noting that the LPN is
competent in the task (dressing changes or suctioning).
21
Mastering Difficult Questions
●●
Let’s take a look at the following question:
A charge nurse is making assignments for three RNs and one licensed practical nurse (LPN). The charge nurse plans to assign the
LPN to the client who
A. is scheduled for a routine colonoscopy this afternoon.
B. is in balanced skeletal traction and had surgery 2 days ago.
C. has type 1 diabetes mellitus and is scheduled for discharge today.
D. has thick secretions from a tracheostomy that was performed yesterday.
●●
●●
●●
●●
●●
The client in the first option is having a diagnostic test and therefore, requires teaching. An LPN cannot legally care
for this client.
The second option describes a client in traction, which is within the scope of LPN practice guidelines if the RN
verifies competency.
The third option includes a teaching requirement, and the LPN cannot legally teach.
Normally, a LPN could care for the client in the fourth option. However, in this case, there is a possible life and
death issue. The word “thick” implies that the client has a possible fluid-volume deficit. So, an RN needs to deal
with the ineffective airway clearance from the tenacious secretions so that the client can breathe more easily.
The correct answer is B. The LPN can care for the client who is in traction after the RN verifies the LPN’s competency
in the task.
NCLEX-PN TIPS
22
Conclusion
CONCLUSION
●●
●●
The very simple and straightforward strategies that you’ve learned in this module can help you:
◯◯
Answer the question being asked by eliminating information that is irrelevant.
◯◯
Use what you know in situations where you doubt your understanding of the topic.
◯◯
Get the most difficult questions correct through identification of priority situations and life and death issues.
Understanding these strategies is a great beginning, but don’t stop here. As you prepare for the NCLEX-PN, use these
strategies on practice tests and refer to this module often to reinforce what you’ve learned. The more you practice,
the sooner these strategies will become second nature to you. By the time you take the exam, your approach to
the test items will be systematic and objective. Remember, wherever you work or whatever position you hold, the
nursing profession is wonderfully challenging and rewarding. Your future begins now. You may begin.
NCLEX-PN TIPS
23
Conclusion
BIBLIOGRAPHY
Bloom, B. S., Engelhart, M. D., Furst, E. J., Hill, W. H., & Krathwohl, D.R. (1956). Taxonomy of
educational objectives: The classification of educational goals. Handbook
I. Cognitive Domain. New York: David McKay.
Ignatavicius, D. D. & Workman, M. L. (2010). Medical-surgical nursing: Critical thinking for
collaborative care (6th ed.). Philadelphia: W.B. Saunders Co.
Lehne, R. A. (2010). Pharmacology for nursing care. (7th ed.). St. Louis: W.B. Saunders Co.
Lowdermilk, D. L., & Perry, S. E. (2007). Maternity and women’s health Care (9th ed.). St. Louis, MO: Mosby.
National Council of State Boards of Nursing. (2011). National Council of State Boards of Nursing
detailed test plan for the NCLEX-PN® examination. Retrieved September 6, 2011, from
www.ncsbn.org/index.htm.
Potter, P. A., & Perry, A. G. (2009). Fundamentals of nursing (7th ed.). St. Louis, MO: Mosby.
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