Davis's Q&A for the NCLEX-RN Examination

Chart/Exhibit Practice Item While performing a physical assessment on a client with a long- term history of tobacco use, a nurse notes changes in the client’s fingers (see illustration). Angle > 180 The nurse should best document this assessment finding as: 1. vitiligo. 2. clubbing. 3. keratinized. 4. poor capillary refill. ANSWER: 2 In this question, the nurse should document the finding as clubbing. The picture shows swelling at the distal end of the finger and loss of the normal 160-degree angle between the base of the nail and the skin. Clubbing results from oxygen deficiency and is often seen in clients with congenital heart defects and long-term use of tobacco. Options 1, 3, and 4 are incorrect findings. Vitiligo is patchy loss of skin pigmentation. Keratinized tissues would be hard or horny. There is no indica- tion that capillary refill has been tested. Test-takingTip:To answer items in the chart/exhibit format, identify key words in the stem, such as “history of tobacco use” and “best document.” Next, focus on the illustration or display and review the accompanying data carefully. Determine what the question is asking. Content Area: Fundamentals; Category of Health Alteration: Basic Care and Comfort; Integrated Processes: Communication and Documentation; Client Need: Health Promotion and Maintenance/Techniques of Physical Assessment; Cognitive Level: Application Reference: Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (8th ed., pp. 582–583). Upper Saddle River, NJ: Pearson Education. ANSWER: 1 The “tri-foil” is the international symbol for radiation. The symbol can be magenta or black, on a yellow background. Option 2 is a universal biohazard symbol indicating a potentially infectious specimen. Option 3 is the symbol used to identify the hazard of a chemical using the National Fire Protection Associa- tion’s (NFPA) diamond. The blue diamond indicates a health hazard; with the number 3 indicating that it could cause serious injury even if treated. Red is flammability, with number 2 indi- cating that it must be preheated for flammability. The flash point is above 200°F. Yellow is the level of reactivity hazard, with a number 1 indicating that it may cause irritation. The symbol “W” indicates the substance has a special hazard of reacting when mixed with water. Option 4 is the Mr. Yuk symbol indicat- ing that a substance is a poison. Test-takingTip:To answer items in the graphic format, identify key words in the stem, such as “radiation.” Next, focus on the various graphics provided and eliminate options by deciphering the meaning of each graphic. Content Area: Fundamentals; Category of Health Alteration: Safety, Disaster Preparedness, and Infection Control; Integrated Processes: Nursing Process Planning; Client Need: Safe and Effective Care Environment/Safety and Infection Control/Accident Prevention; Cognitive Level: Application Reference: Potter, P., & Perry, A. (2009). Fundamentals of Nursing (7th ed., p. 845). St. Louis, MO: Mosby/Elsevier. BOX 2.11 Graphic Practice Item A nurse is planning care for a client who is to receive a radiation treatment later in the day. In preparing the client’s room, which sign should the nurse plan to post outside the client’s room? 1. 2. 3. 4. BOX 2.12 Audio Practice Item BOX 2.13 Safe and Effective Care Environment Management of Care: Providing and directing nursing care that enhances the care delivery setting to protect clients, family/significant others, and health-care personnel. CHAPTER 2 NCLEX-RN® Items 17 Place your headset on now. Click the Play button to listen to the audio clip. Based on the audio clip, which lung sound is the nurse hearing upon auscultation? 1. Crackles 2. Wheezes 3. Plural friction rub 4. Rhonchi An unresponsive client is admitted to an emergency room. The client’s cardiac rhythm is extremely irregular with no measurable heart rate, no P waves, and no QRS complexes. A nurse leading the resuscitation team should direct the team to perform which action first? 1. Defibrillate 2. Administer epinephrine 3. Perform synchronized cardioversion 4. Prepare for pacemaker insertion ANSWER: 1 The client’s signs are characteristic of ventricular fibrillation. Immediate defibrillation is the best intervention for termi- nating the life-threatening arrhythmia. Epinephrine should be administered according to advanced cardiac life support pro- tocols after defibrillation. Synchronized cardioversion should be performed on a client with atrial fibrillation or atrial flutter. A QRS complex must be present to synchronize the shock. A pacemaker insertion at this time is inappropriate. Test-taking Tip: Note the key word “first.” Since the client’s heart rate is absent and the rhythm irregular, eliminate options 2, 3, and 4. Content Area: Adult Health; Category of Health Alteration: Cardiac Management; Integrated Processes: Nursing Process Implementation; Client Need: Safe and Effective Care Environment/Management of Care/Delegation; Cognitive Level: Analysis Reference: Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L. (2007). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (7th ed., p. 855). St. Louis, MO: Mosby. 18 SECTION I Preparing for the NCLEX-RN® BOX 2.14 Safe and Effective Care Environment Safety and Infection Control: Protecting clients, family, significant others and health-care personnel from health and environmental hazards. A nurse reports to employee health services for an injury to the hand from a needle stick. The needle was used on a client who is known to be HIV positive. Which interventions should be taken by the occupational health nurse in employee health services? SELECT ALL THAT APPLY. 1. Wash the exposed site with soap and water 2. Test for HIV antigens now, in 6 weeks, and then again in 3 months 3. Administer postexposure prophylaxis medications within 1 to 2 hours 4. Counsel on safe sexual practices until follow-up testing is complete 5. Place the employee on leave until testing indicates the employee’s HIV status is negative ANSWER: 1, 3, 4 Occupational blood exposure is an urgent medical concern and care should be sought immediately. Washing can reduce the amount of virus present and may prevent transmission. After an HIV exposure, infection may have occurred even though tests for HIV are negative; it may take up to 1 year for the development of a positive antibody test. Prophylactic treatment is started as soon as possible (preferably within 1 to 2 hours) and lasts for 4 weeks. If results of HIV-antibody testing return positive, treatment continues. HIV-antibody (not antigen) testing is completed at baseline, 6 weeks, 3 months, and 6 months after exposure. Initially, the employee may be sent home on sick leave. However, an employee who is HIV positive can continue to work, but must cover open skin areas and avoid client contact when open skin lesions are present. Test-taking Tip: Apply disease prevention principles. The options that will prevent developing the disease are options 1 and 3. Option 4 prevents the transmission of HIV. Content Area: Adult Health; Category of Health Alteration: Infectious Disease and Autoimmune Responses; Integrated Processes: Nursing Process Implementation; Client Need: Safe Effective Care Environment/Safety & Infection Control/Reporting of Incident/Event/Irregular Occurrence/Variance; Cognitive Level: Analysis References: Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2008). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (11th ed., pp. 1819–1821). Philadelphia: Lippincott Williams & Wilkins; Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (8th ed., pp. 859–860). Upper Saddle River, NJ: Pearson Education. EBP Reference: Panlilio, A.L., Cardo, D., Grohskopf, L., Heneine, W., & Ross, C. (2005, September 30). Updated U.S. public health service guidelines for the man- agement of occupational exposures to HIV and recommendations for post-exposure prophylaxis. MMWR, 54(RR09),1–17. Available at: BOX 2.15 Health Promotion and Maintenance The nurse provides care and directs nursing care of the client, family/significant others, that incorporates the knowledge of expected growth and development principles, prevention and/or early detection of health problems, and strategies to achieve optimal health. CHAPTER 2 NCLEX-RN® Items 19 When communicating with a normally developed 2-year-old about to undergo a diagnostic test, the nurse would expect the child to communicate: 1. by pointing and imitating. 2. using at least 6 words. 3. in two-word sentences. 4. using complete sentences. ANSWER: 3 The language development at 24 months includes two-word sentences (a noun-pronoun and verb), such as “Daddy go” and a vocabulary of around 50 words. A child with a hearing impairment who has not acquired language skills would commu- nicate by pointing or imitating. At 15 months, 4 to 6 words are used and at 18 months, 7 to 20. Using full sentences would be the communication skills of a 4 to 5 year old. Test-taking Tip: Visualize a 2-year-old and the language skills before reading each option. Content Area: Child Health; Category of Health Alteration: Growth and Development; Integrated Processes: Communication and Documentation; Client Need: Health Promotion & Maintenance/Growth and Development; Cognitive Level: Application Reference: Pillitteri, A. (2007). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family (5th ed., p. 865). Philadelphia: Lippincott Williams & Wilkins. BOX 2.16 Psychosocial Integrity The nurse provides and directs nursing care that promotes and supports the emotional, mental, and social well- being of the client and family/significant others experiencing stressful events, as well as clients with acute or chronic mental illness. A registered nurse is orienting a new nurse. Together, they are caring for a group of clients diagnosed with enlarged prostates and each is scheduled for a radical prostatectomy. The registered nurse tells the new nurse that one client is likely to need addi- tional support due to the client’s high risk for prostate cancer. To which client is the registered nurse most likely referring? 1. 50-year-old Korean man 2. 50-year-old Hispanic man 3. 50-year-old Caucasian man 4. 50-year-old African American man ANSWER: 4 African American men develop cancer twice as often as white men and at an earlier age. Cancer of the prostate is rare before age 39, but increases with each decade. Asian and Hispanic men have a lower incidence and mortality from prostate cancer than Caucasian men. Caucasian men develop prostate cancer less commonly than African American men, but more commonly than Korean and Hispanic men. Test-taking Tip: Focus on the key words “high risk.” Knowledge of cultural differences in the development of prostate cancer is needed to answer this question. Content Area: Adult Health; Category of Health Alteration: Reproductive Management; Integrated Processes: Caring; Teaching/Learning; Client Need: Psychosocial Integrity/ Cultural Diversity; Cognitive Level: Application Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical Nursing: Critical Thinking for Collaborative Care (5th ed., p. 1865). St. Louis, MO: Elsevier/Saunders. 20 SECTION I Preparing for the NCLEX-RN® BOX 2.17 Physiological Integrity Basic Care and Comfort: Providing comfort and assistance in the performance of activities of daily living. A nurse is calculating the amount of urine output at the end of an 8-hour shift for a client who has a continuous bladder irriga- tion after a transurethral resection of the prostate (TURP). The nurse emptied the urinary drainage bag twice during the shift. The first time there was 900 mL and the second time there was 1,000 mL. The amount of irrigation hung at the beginning of the shift was 3,000 mL, and there is 1,600 mL left at the end of the shift. The nurse should record that the client had _____ mL of urine output over the 8-hour period. Fill in the blank. ANSWER: 500 Determine the amount of irrigation solution used: 3,000 – 1,600 = 1,400. Next, subtract the 1,400 mL of irrigation used from the combined amounts in the urinary drainage bag: 1,900 – 1,400 = 500. The client had 500 mL of urine output during the past 8 hours. Test-taking Tip: Read the question carefully to understand what the question is asking. Use the calculator provided on the NCLEX-RN® examination and double-check calculations that seem unusually large. Content Area: Adult Health; Category of Health Alteration: Renal and Urinary Management; Integrated Processes: Communication and Documentation; Client Need: Physiological Integrity/Basic Care and Comfort/Elimination; Cognitive Level: Analysis Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical Nursing: Critical Thinking for Collaborative Care (5th ed., p. 1860). St. Louis, MO: Elsevier/Saunders. BOX 2.18 Physiological Integrity Pharmacological and Parenteral Therapies: Providing care related to the administration of medications and parenteral therapies. A nurse is administering promethazine (Phenergan®) to a postoperative client. In evaluating the effectiveness of the medication, which finding should the nurse anticipate? 1. Absence of pain 2. Decrease in heart rate 3. Increase in urine output 4. Absence of nausea and vomiting ANSWER: 4 Promethazine (Phenergan®) has inhibitory effects on the chemoreceptor trigger zone in the medulla with resultant antiemetic properties. It does not have analgesic properties or affect urinary elimination. Bradycardia is a side effect of promethazine. Test-taking Tip: Note the key word “evaluating.” Look for the desired action of the medication. Content Area: Adult Health; Category of Health Alteration: Perioperative Management; Integrated Processes: Nursing Process Evaluation; Client Need: Physiological Integrity/ Pharmacological & Parenteral Therapies/Expected Effects/ Outcomes; Cognitive Level: Application Reference: Deglin, J., & Vallerand, A. (2009). Davis’s Drug Guide for Nurses (11th ed., pp. 1017–1020). Philadelphia: F. A. Davis. BOX 2.19 Physiological Integrity Reduction of Risk Potential: Reducing the likelihood that clients will develop complications or health problems related to existing conditions, treatments, or procedures. The spouse of a client discharged following a transurethral prostatectomy (TURP) calls a clinic because the client continues to have pink-tinged urine 2 days after the procedure. Which response by the nurse is most appropriate? 1. “Bring him right into the clinic so that we can evaluate why his urine is pink-tinged.” 2. “This is normal. His urine will be pink-tinged for several days after the procedure.” 3. “Is he eating more leafy green vegetables or taking any over-the-counter medications?” 4. “His urine should be clear amber by now so there might be bleeding. Increase his fluids.” ANSWER: 2 The client may continue to pass small clots and tissue debris and have pink-tinged urine for several days after surgery. It is unnecessary to bring the client to the clinic immediately unless the urine is dark red or burgundy, indicating arterial or venous bleeding, respectively. Leafy green vegetables and over- the-counter medications may enhance the effects of anticoagu- lants. However, this is irrelevant to the situation since the client should not be taking anticoagulants. Having the client’s spouse increase his fluid intake will flush the urinary system. However, pink-tinged urine, at this time, is normal. Test-taking Tip: Focus on the issue in the stem: pink- tinged urine 2 days afterTURP. Eliminate responses 1, 3, and 4 because these imply that the client is bleeding. Content Area: Adult Health; Category of Health Alteration: Renal and Urinary Management; Integrated Processes: Communication and Documentation; Client Need: Physiological Integrity/Reduction of Risk Potential/Potential Complications; Cognitive Level: Application Reference: Black, J., & Hokanson Hawks, J. (2009). Medical-Surgical Nursing: Clinical Management for Positive Outcomes. (8th ed., pp. 882–884). St. Louis, MO: Saunders/Elsevier. CHAPTER 2 NCLEX-RN® Items 21 BOX 2.20 Physiological Integrity Physiological Adaptation: Managing and providing care for clients with acute, chronic, life-threatening physical health conditions. Which nursing diagnosis is the highest priority for the client ex- periencing heart failure? 1. Excess fluid volume 2. Disturbed sleep pattern 3. Activity intolerance 4. Impaired gas exchange ANSWER: 4 Impaired gas exchange is a basic physiological need according to Maslow’s Hierarchy of Needs theory and is the priority nursing diagnosis. Although excess fluid volume is experienced in heart failure, impaired gas exchange would be a higher priority. Disturbed sleep patterns and activity intolerance also may occur in heart failure, but these would be a second-level need for safety and security. Test-taking Tip: Note the key word “priority.” Use Maslow’s Hierarchy of Needs theory to select the basic physiological need for air as the first priority. Content Area: Adult Health; Category of Health Alteration: Cardiac Management; Integrated Processes: Nursing Process Analysis; Client Need: Physiological Integrity/Physiological Adaptation/Illness Management; Cognitive Level: Analysis Reference: Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L. (2007). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (7th ed., pp. 836–837). St. Louis: MO: Mosby. 22 SECTION I Preparing for the NCLEX-RN® References Anderson, L. W., & Krathwohl, D. R. (Eds.). (2001). A Taxonomy for Learning, Teaching, and Assessing. A Revision of Bloom’s Taxonomy of Educational Objectives. New York: Addison Wesley Longman. Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Prac- tice (8th ed., pp. 582–583). Upper Saddle River, NJ: Pearson Education. Black, J., & Hokanson Hawks, J. (2009). Medical-Surgical Nurs- ing: Clinical Management for Positive Outcomes (8th ed.). St. Louis, MO: Saunders/Elsevier. Bloom, B. S. (Ed). (1956). Taxonomy of Educational Objectives: The Classification of Educational Goals, Handbook. New York: David McKay. Deglin, J., & Vallerand, A. (2010). Davis’s Drug Guide for Nurses (12th ed.). Philadelphia: F. A. Davis. Ignatavicius, D., & Workman, M. (2006). Medical-Surgical Nursing: Critical Thinking for Collaborative Care (5th ed.). St. Louis, MO: Elsevier/Saunders. Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L. (2007). Medical-Surgical Nursing: Assessment and Man- agement of Clinical Problems (7th ed.). St. Louis, MO: Mosby. National Council of State Boards of Nursing. (2009). NCLEX-RN® Examination Candidate Bulletin. Chicago: Author. National Council of State Boards of Nursing. (2009). NCLEX-RN® Examination: Test Plan for the National Council Licensure Examination for Registered Nurses, Effective April 2010. Chicago: Author. National Council of State Boards of Nursing. (2009). Frequently Asked Questions about the 2010 NCLEX-RN® Test Plan. Chicago: Author. National Council of State Boards of Nursing. (2009). NCLEX-RN® Program Reports. Chicago: Author. National Council State Board of Nursing. (2009). Alternate Format Items. Chicago: Author. Nugent, P. M., & Vitale, B. A. (2008). Test Success: Test-taking Techniques for Beginning Nursing Students (5th ed.). Philadelphia: F. A. Davis. Panlilio, A. L., Cardo, D., Grohskopf, L., Heneine, W., & Ross, C. (2005, September 30). Updated U.S. public health service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR 54(RR09), 1–17. Available at: Pickar, G. D. (2007). Dosage Calculations: A Ratio-Proportion Approach (2nd ed.). Clifton Park, NY: Thomson Delmar Learning. Registered Nurses Association of Ontario (RNAO). (2005). Nurs- ing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD). Toronto, ON: Author. Available at: Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2008). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (11th ed.). Philadelphia: Lippincott Williams & Wilkins. Wilkinson, J., & Van Leuven, K. (2007). Fundamentals of Nurs- ing: Thinking & Doing (Vol. 2). Philadelphia: F. A. Davis. Williams, L., & Hopper, P. (2007). Understanding Medical- Surgical Nursing (3rd ed.). Philadelphia: F. A. Davis. Test-Taking Tips and Strategies Taking the NCLEX-RN® examination can be a stressful experience. Thus, this chapter is designed to help you find ways to read NCLEX-type questions and answer them cor- rectly. Understanding how to take a test and to use strate- gies to answer test items is just as important as knowing the content. Some test-taking tips are presented in this chapter to help you improve your testing abilities and to pass the NCLEX-RN® examination. Use these strategies and tips to identify the best option to answer a question or complete an item. You can also use these strategies to select an answer for unfamiliar content or for items for which you are uncer- tain of the answer. CAREFULLY READ THE NCLEX-RN® ITEMS AND FOCUS ON THE SUBJECT NCLEX-RN® examination questions are often long and contain more information than what is specifically needed to answer the question. Most questions consist of a case scenario, the question or item stem, and the answer options. Therefore, make sure to read the entire question thoroughly and focus on what the question is asking. As you read the question, try to answer the question before looking at the options to see if you understand what the question is asking. If you do not know the answer, then rephrase the question in your own words. This may make it easier to understand what the question is asking. Be sure to read the entire question before reading the options. Decide what information is relevant and what can be omitted. Ask yourself, “What is the question asking?” Focus on the last line of the question. This is the stem of the question and will state what the question is asking or looking for in an answer. In the stem of the question, look for key words such as priority, first, or best. Note the age of the client. If the age is not specified, then assume the client is an adult and answer the question based on princi- ples of adult growth and development or physiological or psychological problems related to adults. In a multiple-choice question, there will be four answer options and you must select one. Read all of the options thoroughly before selecting an answer. A multiple-response question has many options and you must select all that apply. In a prioritization question, you must list items in order, usually from the highest priority to the lowest prior- ity. These prioritization items can be diverse and include such items as priority of assessments, interventions, nursing skills, pathophysiological concepts, or a variety of other situations that can be sequenced. THE NURSING PROCESS After carefully reading the question and options, consider if the nursing process is applied in the question versus the other integrated processes of caring, teaching and learning, or communication and documentation. If the nursing process is being applied, decide which step in the process is the focus of the question. The five steps of the nursing process include (1) assessment, (2) analysis or diagnosis, (3) plan- ning, (4) implementation, and (5) evaluation. A complete description of each step in the process is included in Chapter 1, The NCLEX-RN® Licensure Examination. Because the nursing process incorporates critical thinking, the licensure examination is designed to test your use of this process within the nursing role and scope of practice. When a step of the nursing process is applied in a question, examine each option to be sure that the option corresponds to that step of the nursing process. For exam- ple, if the focus of the question is on assessment but options include implementation, eliminate any options pertaining to implementation as an answer choice. Table 3.1 identifies each step of the nursing process and key words used for that step in test items. The nursing process can also be used to prioritize actions. Assessment is the first action and thus is the priority in most situations. In a life-threatening situation, if an obser- vation suggests an immediate intervention is needed, only then is an intervention the priority. Boxes 3.1 through 3.5 illustrate using the steps in the nursing process as a test- taking strategy. If after reviewing the examples further expla- nation is needed, a detailed process for analyzing questions using the nursing process and more specific examples can be found in Test Success by Nugent and Vitale (2008). Chapter Three 23 24 SECTION I Preparing for the NCLEX-RN® TABLE 3.1 Steps of the Nursing Process and Key Words in Test Items Nursing Process Step Key Words Key Words Key Words Assessment adaptations ascertain assess check collect communicate determine find out gather identify inform inspect monitor nonverbal notify observe obtain information perceptions question signs and symptoms sources stressors verbal verify Analysis analysis categorize cluster contribute decision deduction formulate interpret nursing diagnosis organize problem reflect relate relevant reexamine significant statement valid Planning achieve anticipate arrange collaborate consult coordinate design desired desired results determine develop effective establish expect formulate goal modify outcome plan prevent priority select strategy Implementation action assist change counsel delegate dependent facilitate give implement independent inform instruct interdependent method motivate perform procedure provide refer strategy supervise teach technique treatment Evaluation achieved compared desired effective evaluate expected failed ineffective met modified reassess response succeeded THE ABCS The ABCs—airway, breathing, and circulation—can be very helpful in answering NCLEX-RN® questions. They can be used when determining the order of priority. Priority-type questions can be identified with words such as first, priority, initial, main concern, and primary. When choosing the correct answer option, if an option pertains to a client’s airway and is pertinent to the situation, then this option should be the nurse’s first priority. If no option pertains to airway, then look for an option that pertains to breathing, and so on. Box 3.6 provides an example of this type of item. MASLOW’S HIERARCHY OF NEEDS Maslow’s Hierarchy of Needs theory states that physiologi- cal needs are the most basic human needs (Fig. 3.1); use it as another guide to help prioritize the options to assist in selecting the correct option. Physiological needs are the pri- ority; therefore, physiological needs should be met before psychosocial needs. When a physiological need is not pre- sented in the question or included as one of the answer op- tions, continue using Maslow’s Hierarchy of Needs theory and look for the answer option that addresses safety. Con- tinue to move up the hierarchy ladder to identify the prior- ity if needs at the lower levels are not addressed within the CHAPTER 3 Test-Taking Tips and Strategies 25 BOX 3.1 Nursing Process Assessment Practice Item A nurse is caring for a hospitalized 10-year-old client who has chest contusions from a motor vehicle accident. The client is on room air and is being monitored by a pulse oximeter. When the nurse enters the room, the pulse oximeter monitor is alarming and is showing an oxygen saturation of 84%. The nurse should immediately: 1. call the physician for an order for arterial blood gases (ABGs). 2. assess the client’s level of consciousness and skin color. 3. replace the machine and probe. 4. administer oxygen through a nasal cannula or by mask. ANSWER: 2 By immediately evaluating the client’s mental status and skin color, the nurse can quickly determine whether or not the sig- nal tracing constitutes an emergency or if it is an artifact. An artifact in the pulse oximeter monitoring system can be caused by altered skin temperature, movement of the client’s finger, or probe disconnection. Equipment malfunction can also occur. Calling the physician is necessary only if the reading is accurate. Replacing the machine is only necessary if the ma- chine is malfunctioning. Applying oxygen may be necessary if the nurse is unable to determine the client’s pulse oximeter read- ing within a few seconds. Test-taking Tip: Because assessment is the first step in the nursing process and the situation requires additional information before an intervention can be determined, assessment should be the first action in this situation. Options pertaining to interventions should be eliminated. Content Area: Child Health; Category of Health Alteration: Respiratory Management; Integrated Processes: Nursing Process Assessment; Client Need: Physiological Integrity/ Physiological Adaptation/Medical Emergencies; Cognitive Level: Analysis References: Ball, J., & Bindler, R. (2008). Pediatric Nursing: Caring for Children (4th ed., pp. 685–687). Upper Saddle River, NJ: Pearson Education; Clark, A., Giuliano, K., & Chen, H. (2006). Legal and ethical: Pulse oximetry revisited: “but his O2 sat was normal!” Clinical Nurse Specialist: The Journal for Advanced Nurs- ing Practice, 20, 268–272; Potter, P., & Perry, A. (2009). Fundamentals of Nursing (7th ed., pp. 534–535). St. Louis, MO: Mosby Elsevier. ANSWER: 4 Anorexia can be severe in the acute phase of hepatitis. Distaste for cigarettes in smokers is characteristic of early profound anorexia. Heartburn at night is a symptom of gastroesophageal re- flux disease (GERD). Diarrhea after eating dairy products can be a symptom of lactose intolerance. Increasing shortness of breath can be related to circulatory or respiratory concerns. Test-taking Tip: Analysis questions require understanding of the physiological processes and interpretation of information. In this question, thinking about the signs and symptoms associated with hepatitis is necessary to analyze the client’s statements and eliminate options that are inconsistent with the diagnosis. The process of elimination can also be used to eliminate option 3 because it is a sign of activity intolerance often associated with cardiopulmonary problems. Content Area: Adult Health; Category of Health Alteration: Infectious Disease; Integrated Processes: Nursing Process Analysis; Client Need: Physiological Integrity Reduction of Risk Potential/Potential for Alterations in Body Systems; Cognitive Level: Application Reference: Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L. (2007). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (7th ed., pp. 825; 1004, 1081, 1091). St. Louis, MO: Mosby. BOX 3.2 Nursing Process Analysis Practice Item A client is admitted with a tentative diagnosis of hepatitis. A nurse determines which client statement would be consistent with the diagnosis? 1. “I have not been sleeping well because I have so much heartburn at night that it wakes me up.” 2. “Whenever I eat dairy products I have diarrhea for a few days.” 3. “Lately I have been short of breath during my walk from the bus stop to work.” 4. “I am a smoker but lately I can’t tolerate the taste of cigarettes.” 26 SECTION I Preparing for the NCLEX-RN® BOX 3.3 Nursing Process Planning Practice Item A client is admitted with vancomycin-resistant enterococci (VRE) in a leg wound. The wound is draining although dressings are covering the wound. To prevent the spread of the VRE, which is a nurse’s best plan of action? 1. Assign the client to a private room 2. Assign only one caregiver to the client 3. Do not allow pregnant staff to enter the room 4. Place the client in a negative-airflow room ANSWER: 1 Single-client rooms are preferred when there is a concern about transmission of an infectious agent. It is not practical to assign only one caregiver, as the client will likely require multi- ple caregivers throughout hospitalization. VRE is not spread to pregnant staff at higher rates than to nonpregnant staff. A nega- tive-airflow room is required for airborne diseases. VRE is not an airborne disease. Test-taking Tip: This question is a nursing process planning item that includes planning care for a client. First determine if all options should be included in the nurse’s plan. The key words are “best plan of action.” Recall that VRE can be transmitted to others, but is not airborne. Eliminate option 4. Of the remaining options, determine which is best. Content Area: Fundamentals; Category of Health Alteration: Safety, Disaster Preparedness, and Infection Control; Integrated Processes: Nursing Process Planning; Client Need: Safe Effective Care Environment/Safety and Infection Control/Standard Precautions/Transmission-based Precautions; Cognitive Level: Analysis Reference: Craven, R., & Hirnle, C. (2009). Fundamentals of Nursing: Human Health and Function (6th ed., pp. 462–465). Philadelphia: Lippincott Williams & Wilkins. EBP Reference: Siegel, J., Rhinehart, E., Jackson, M., Chiarello, L., & the Health- care Infection Control Practices Advisory Committee. (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Atlanta, GA. Available at: CHAPTER 3 Test-Taking Tips and Strategies 27 BOX 3.4 Nursing Process Implementation Practice Item A postpartum client who delivered an infant vaginally has an outcome written in the plan of care, “To be free of perineal and uterine infection during the postpartum period.” Which interven- tions should a nurse include in the client’s care to promote meet- ing this outcome? SELECT ALL THAT APPLY. 1. Instruct the client on wiping the anal area first after voiding and bowel movements 2. Apply the perineal pad from front to back when changing pads 3. Teach the client to use a “peri” bottle to apply warm water over her perineum after elimination 4. Teach the client to avoid changing the perineal pads more than once a day 5. Prepare a Sitz bath at least once during the shift 6. Assess the level of the fundus every shift ANSWER: 2, 3, 5 The perineal pads should be applied from front (area under the symphysis pubis) and proceed toward the back (area around the anus) to prevent carrying contamination from the anal area to the perineum and vagina. Squirting the per- ineum with water after elimination cleanses the area and promotes comfort. Sitz baths increase circulation to tissues, which promotes healing and thus reduces the risk of infec- tion. The client should be taught to wipe the perineum after elimination from front (area under the symphysis pubis) and pro- ceed toward the back (area around the anus) to prevent carrying contamination from the anal area to the perineum and vagina. Per- ineal pads should be changed at least four times a day to decrease the risk of promoting bacteria growth in the lochia on the pad and transferring that bacteria to the perineum or vagina. Assessing the level of the fundus is not an intervention; it is an assessment. Test-taking Tip: Implementation questions include providing care and teaching. Option 6 pertains to assessment and should be eliminated. Next, eliminate interventions in options 1 and 4 because these would promote bacterial growth rather than prevent an infection. Content Area: Childbearing; Category of Health Alteration: Postpartal Management; Integrated Processes: Nursing Process Implementation; Client Need: Physiological Integrity Reduction of Risk Potential/Therapeutic Procedures; Cognitive Level: Application References: Davidson, M., London, M., & Ladewig, P. (2008). Olds’ Maternal- Newborn Nursing & Women’s Health Across the Lifespan (8th ed., pp. 1078–1080). Upper Saddle River, NJ: Prentice Hall Health; Wong, D., Hockenberry, M., Wilson, D., Perry, S., & Lowdermilk, D. (2006). Maternal Child Nursing Care (3rd ed., pp. 610–611). Philadelphia: Lippincott Williams & Wilkins. ANSWER: 4 The client correctly demonstrating preparing the insulin pen and administering the insulin suggests that the teaching about insulin therapy was effective. Options 1 and 3 are nursing inter- ventions using various teaching strategies. Option 2 is a client ac- tion but it does not demonstrate that learning has occurred. Test-taking Tip: Focus on what the question is asking, “indicates teaching . . . was effective” and the nursing process step of evaluation. Options that include nursing interventions should be eliminated as well as any options with client behaviors that do not demonstrate that learning has occurred. Content Area: Fundamentals; Category of Health Alteration: Medication Administration; Integrated Processes: Nursing Process Evaluation; Client Need: Health Promotion and Maintenance/Principles of Teaching and Learning; Cognitive Level: Application Reference: Harkreader, H., Hogan, M., & Thobaben, M. (2007). Fundamentals of Nursing (3rd ed., p. 284). St. Louis, MO: Saunders/Elsevier. BOX 3.5 Nursing Process Evaluation Practice Item A nurse is evaluating teaching for a client who has diabetes and is beginning insulin therapy using an insulin pen. Which behav- ior should best indicate to a nurse that teaching about the insulin therapy was effective? 1. The nurse showing the client a video that explains how to use the insulin pen 2. The client reading a handout that describes the different types of insulin and insulin pens 3. The nurse demonstrating the correct procedure for preparing the insulin pen for administration 4. The client preparing the insulin pen and self-injecting cor- rectly on the first attempt 28 SECTION I Preparing for the NCLEX-RN® BOX 3.6 The ABCs Practice Item A 5-year-old child who is brought to an emergency room is ex- periencing dyspnea and swelling of the lips and tongue. Audible wheezes, rhinitis, and stridor are also present, and the child is very anxious. Based on these assessment findings, a nurse should first: 1. administer oxygen. 2. assess the child’s vital signs. 3. administer subcutaneous epinephrine per physician’s order. 4. place an intravenous (IV) line to administer antianxiety and other emergency medications. ANSWER: 1 Securing the airway and administering oxygen is an initial intervention. The child is most likely presenting with symp- toms directly related to anaphylactic shock, a potentially life- threatening systemic reaction to an allergen. All of the other interventions are needed to reverse anaphylaxis. The child’s vital signs should be known before administering any medications, but that is not the first assessment priority because the informa- tion already suggests a life-threatening situation and an interven- tion is required. Although all of the other interventions are important, they are not the first action. Adrenalin (epinephrine) is an adrenergic (sympathomimetic) agent and cardiac stimulant used to treat anaphylactic shock. An IV line is needed for medications that can act quickly. Agitation increases oxygen demands. Test-taking Tip: Use the ABCs (airway, breathing, circulation) to identify the initial action. Airway is the priority in this situation. In a life-threatening situation, further assessment is not the priority when an observation provides sufficient information to act. Physiological needs are also priority over psychosocial needs; thus the psychosocial option can be eliminated as the priority action. Content Area: Child Health; Category of Health Alteration: Medical Emergencies; Integrated Processes: Nursing Process Implementation; Client Need: Physiological Integrity/Physiological Adaptation/Medical Emergency; Cognitive Level: Analysis Reference: Ball, J., & Bindler, R. (2008). Pediatric Nursing: Caring for Children (4th ed., pp. 685–687). Upper Saddle River, NJ: Pearson Education. question or options. Box 3.7 provides an example of apply- ing Maslow’s Hierarchy of Needs in a practice item. SAFETY Safety is a high priority in NCLEX-RN® questions. Care- fully read each question and answer options. If an option pertains to safety, which describes a situation that could be life-threatening and affects a physiological need, then safety may be the answer rather than a physiological need that would not be life-threatening. For example, the nursing di- agnosis Risk for injury related to use of restraints takes pri- ority over the nursing diagnosis Disturbed sleep pattern re- lated to unfamiliar surroundings. Although sleep is a basic physiological need, an injury could be life-threatening. Box 3.8 provides an example of applying the principles of safety to practice items. THERAPEUTIC COMMUNICATION Some questions relate to therapeutic communication and the nurse’s ability to communicate with a client. Therapeu- tic communication includes both verbal and nonverbal SELF- ACTUALIZATION (The individual possesses a feeling of self-fulfillment and the realization of his or her highest potential.) SELF-ESTEEM ESTEEM-OF-OTHERS (The individual seeks self-respect and respect from others; works to achieve success and recognition in work; desires prestige from accomplishments.) LOVE AND BELONGING (Needs are for giving and receiving of affection; companionship; satisfactory interpersonal relationships; and the identification with a group.) SAFETY AND SECURITY (Needs at this level are for avoiding harm; maintaining comfort; order; structure; physical safety; freedom from fear; protection.) PHYSIOLOGICAL NEEDS (Basic fundamental needs including food, water, air, sleep, exercise, elimination, shelter, and sexual expression.) Figure 3-1 Applying Maslow’s Hierarchy of Needs to establish priorities. (Adapted from Williams, L. & Hopper, P. (2007). Understanding Medical-Surgical Nursing (3rd ed., Fig. 1-3). Philadelphia: F. A. Davis.) CHAPTER 3 Test-Taking Tips and Strategies 29 BOX 3.7 Maslow’s Hierarchy of Needs Practice Item A client hospitalized with a history of vomiting and diarrhea for 2 days has weakness, lethargy, serum CO2 of 18 mEq/L, and ab- dominal cramping. The client reports an inability to eat due to nausea. Which should be the nurse’s priority nursing diagnosis when caring for the client? 1. Altered nutrition less than body requirements related to diarrhea as manifested by inability to eat 2. Deficient fluid volume related to vomiting as manifested by weakness and low serum CO2 3. Risk for injury related to weakness and lethargy 4. Acute pain related to increased peristalsis as manifested by abdominal cramping ANSWER: 2 The client is exhibiting signs of fluid volume deficit (dizzi- ness, weakness, and lethargy). The normal CO2 is 20 to 30 mEq/L. The decreased serum CO2 indicates metabolic acidosis, which can be caused by diarrhea. Nutrition, potential for injury, and pain are also concerns, but not the priority, be- cause altered fluid volume can affect perfusion. Test-taking Tip: Note the key word “priority.” Focus on the client’s symptoms and the low serum CO2 level. Use Maslow’s Hierarchy of Needs theory. Basic physiological needs have priority over safety and security needs.The ABCs (airway, breathing, circulation) can also be used because deficient fluid volume can affect circulation. Content Area: Adult Health; Category of Health Alteration: Gastrointestinal Management; Integrated Processes: Nursing Process Analysis; Client Need: Safe and Effective Care Environment/Management of Care/Establishing Priorities; Cognitive Level: Analysis Reference: Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L. (2007). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (7th ed., pp. 322; 1036, 1855). St. Louis: MO: Mosby. ANSWER: 4 The nurse’s priority intervention should be to arrange for a PCA to stay with the client. The client’s immediate safety is the primary concern, and constant observation is the best means of providing a safe environment for this client. Al- though medication may become appropriate, it should not be the first response to manage a client’s behavior. It does not address the issue of observing the client for safety. Transferring the client closer to the nurse’s station does not provide the constant obser- vation that is most appropriate for the client at this time. Asking the client’s family to stay may not be a realistic expectation. Test-taking Tip: Use Maslow’s Hierarchy of Needs theory to determine the priority action. Client safety is always a high priority. Determine which option provides for the most thorough, reasonable, and speedy means of addressing the client’s safety needs. Content Area: Mental Health; Category of Health Alteration: Cognitive, Schizophrenic, and Psychotic Disorders; Integrated Process: Nursing Process Implementation; Client Needs: Psychosocial Integrity/Behaviorial Interventions; Cognitive Level: Analysis Reference: Mohr, W. (2006). Psychiatric-Mental Health Nursing (6th ed., pp. 726–734). Philadelphia: Lippincott Williams & Wilkins. therapeutic and then look for responses that use barriers to therapeutic communication. Therapeutic communication includes using techniques such as silence, broad opening statements, focusing, restating, clarifying, validating messages, interpreting body language, sharing observations, exploring issues, and reflecting. Barriers BOX 3.8 Safety Practice Item A nurse is assessing an elderly postoperative client who is ex- hibiting signs of delirium. The nurse observes that the client is convinced that it is 1954 and is complaining about “the bugs in this hotel.” The nurse’s priority intervention should be to: 1. obtain a prn order for haloperidol (Haldol®). 2. transfer the client to a room near the nurse’s station. 3. call the client’s family to come and stay with the client. 4. arrange for a patient care assistant (PCA) to stay with the client. communication. Normally, communication questions are multiple-choice–type items and incorrect options can be eliminated so that just one answer option remains. The nurse should use communication techniques that focus on the client’s concerns and facilitate communication. There- fore, first eliminate the options that are obviously not 30 SECTION I Preparing for the NCLEX-RN® to therapeutic communication include responses such as changing the subject, inattentive listening, giving false reas- surance, and giving advice. Tables 3.2 and 3.3 provide a description of common therapeutic communication techniques and barriers to therapeutic communication that you may en- counter in the practice items provided or on the NCLEX-RN® examination. Box 3.9 provides an example of applying thera- peutic communication in a practice item. TABLE 3.2 Therapeutic Communication Techniques KEY WORDS Pay attention to key words. There will be questions for which there are more than one correct option; however, based on key words there is only one option that answers the question cor- rectly. Questions may contain key words such as most appro- priate, least appropriate, best, first, last, next, and most helpful. These key words bring your attention to a specific Acknowledging Indicating an awareness of a change in a client’s behavior Focusing Collecting additional information to help gain further knowledge on a topic the client addressed after he or she finishes speaking Giving information Providing accurate information that a client did or did not request Offering general leads Using statements or questions that encourage verbalization, allowing a client to choose the topic of conversation, and facilitating further communication Offering self Simply being present or asking if the client needs anything without expecting a client to give the nurse anything Reflecting Directing the topic to an idea or feeling that a client stated, which allows for further exploration on that feeling or idea Seeking clarification Either stating that what a client said was misunderstood or asking the client to repeat the conversation or basic idea of the message Sharing observations Verbalizing what is observed or perceived, which allows client recognition of specific behaviors to compare perceptions with the nurse Summarizing and planning Restating the main ideas of a conversation to clarify the important points; often done at the end of an interview Using silence Allowing pauses or silences without interjecting a verbal response and allowing a client an opportunity to collect and organize thoughts. Adapted from Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (8th ed., pp. 469–471). Upper Saddle River, NJ: Pearson Education. TABLE 3.3 Barriers to Therapeutic Communication Asking “why” Asking why suggests criticism to some and may result in a defensive response from a client. Belittling the feelings Conveying a lack of empathy and understanding.This may result in a client feeling expressed insignificant or unimportant. Changing the subject Directing the topic into areas of self-interest.This usually indicates that a nurse is unable to handle the topic that is being discussed and avoids listening to what a client is saying and feeling. Giving nonexpert Telling a client what should be done or how to think. Giving advice focuses on a nurse’s advice opinions and ideas and not on the client’s views.This may negate the client’s opportu- nity to participate as a mutual partner in decision making. CHAPTER 3 Test-Taking Tips and Strategies 31 TABLE 3.3 Barriers to Therapeutic Communication (continued) Providing false Using clichés or encouraging statements when the situation’s outcome is not positive or reassurance is unknown.These statements ignore the fears, feelings, and other responses of a client. Interpreting Telling a client the meaning of his or her experience. Passing judgment Giving opinions or approving or disapproving a client’s values.This may result in the client feeling that he or she must think as the nurse thinks and not have his or her own ideas and opinions. Probing Asking unnecessary questions; these questions violate a client’s rights. Rejecting Refusing to discuss certain concerns or topics.This may lead a client to believing that the nurse is rejecting not only the client’s concerns but also the client. Stereotyping Generalizing groups of people based on experiences that a nurse has previously experi- enced; categorizes the client and does not look at each client as an individual. Adapted from Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (8th ed., pp. 469–471). Upper Saddle River, NJ: Pearson Education. BOX 3.9 Therapeutic Communication Practice Item In a written record of a conversation between a nurse and client, which statement by the nurse best encourages therapeutic communication? Client: “I just learned I might have cancer and I am having surgery tomorrow morning.” 1. Nurse: “I see. Why are you afraid? Do you think surgery will reveal that you have cancer?” Client: “I am afraid because I don’t want to have cancer.” 2. Nurse: “Are you afraid that it might be cancer?” Client: “I guess.” 3. Nurse: “Having a possible diagnosis of cancer is frightening. Tell me more about how you are feeling about this.” Client: “I’m afraid I will die. My mother died of cancer when I was 10, and I have a 10 year old.” 4. Nurse: “This really hits close to you.” Client: “Yes. I don’t want my 10 year old to grow up alone.” 1. Response 1 2. Response 2 3. Response 3 4. Response 4 point that you need to consider when answering the question. The key words can indicate a priority or negative polarity. Tables 3.4 and 3.5 provide examples of key words. For priority items, all or most of the options are cor- rect, but you must determine the best option that fits with the key word or phrase to correctly answer the question. ANSWER: 3 The statements in option 3 use therapeutic communication techniques of sharing observations and using an open-ended statement. The statement allows the client to elaborate fur- ther about the client’s feelings and fears, while building a trusting nurse–client relationship. Asking the client “why” questions belittles the client’s feelings and may cause the client to withdraw from the interaction. Response 2 is an example of restating and clarifying the client’s response but it does not stim- ulate further conversation. Asking the client a “yes”/“no” ques- tion, as in response 2, ends the conversation and does not allow for further opportunity to build a relationship. Response 4 is an example of restatement. Although the statement allows the client to further elaborate and is therapeutic, response 3 is the best statement because it uses two therapeutic communication tech- niques, whereas response 4 uses one. Test-takingTip: Read through the written conversation carefully. Choose the option that uses more than one therapeutic communication technique and encourages further communication. Content Area: Adult Health; Category of Health Alteration: Oncological Management; Integrated Processes: Communication and Documentation; Client Need: Psychosocial Integrity/ Therapeutic Communications; Cognitive Level: Analysis Reference: Harkreader, H., Hogan, M., & Thobaben, M. (2007). Fundamentals of Nursing (3rd ed., pp. 266–269). St. Louis, MO: Saunders/Elsevier. Looking for a key word in each of the options that may be a synonym for a key word in the question is also a technique for selecting the correct option. The previously discussed strategies (ABCs, Maslow’s Hierarchy of Needs theory, Nursing Process, and Safety) can be used to determine the best option for items that set a priority with a key word. 32 SECTION I Preparing for the NCLEX-RN® TABLE 3.4 Key Words That Set a Priority Negative polarity items, sometimes called false- response items, are those in which you would select the option that is incorrect. The stem of the item is negatively worded and asks you to identify an exception, detect an error, or identify unacceptable nursing actions or contraindi- cated actions by the nurse or client. Negative polarity items may or may not appear on your NCLEX-RN® examination. ELIMINATE ABSOLUTE WORD OPTIONS Absolute words used in options tend to make those options incorrect. Some absolute words include must, always, never, all, none, every, and only. Eliminating options containing absolute words can make it easier to answer the question. SIMILAR OPTIONS At times there may be two or more options that appear to be similar. When you are answering questions, look for these similar options because they can usually be eliminated in multiple-choice items. For these types of items, there is only one correct option to each question and usually the option of choice is different from those that are similar. Be careful as you read the stem of the question, however, because the option that may be different may not fit with the question or situation presented. Box 3.10 provides an example of a practice item containing similar options. In multiple-response items, look for similar options that can include similar assessment findings, actions, or concepts. Similar options are most likely the correct options in multiple-response types of questions. ANSWER: 4 The greatest threat to the child is a fall. Crib rails should be raised and secured unless an adult is in attendance. Although all options pose a safety threat, the most immediate and serious of these is the crib rails in a halfway position. A 2-year-old child’s developmental stage focuses on mobility and exploring the environment. Crayons can pose a choking hazard if the child should chew on these. Movable eyes in a doll can pose a choking hazard if the eyes can be removed. A mobile could pose a safety risk if the child were to attempt to use this to climb out of bed. Test-taking Tip: Note the similarities in the risk posed in options 1 and 2, that option 3 may or may not pose a risk, and that option 4 presents a different risk. Often, the option that is different is the answer in a multiple- choice type question. Content Area: Child Health; Category of Health Alteration: Hematological and Oncological Management; Integrated Processes: Nursing Process Evaluation; Client Need: Safe and Effective Care Environment/Safety and Infection Control/ Accident Prevention; Cognitive Level: Analysis Reference: Ball, J., & Bindler, R. (2008). Pediatric Nursing: Caring for Children (4th ed., pp. 320–323, 416). Upper Saddle River, NJ: Pearson Education. Best Early Essential First Highest priority Immediate Initial Last Least appropriate Least helpful Least likely Most appropriate Most important Most helpful Most likely Most suitable Next Priority Primary Safest Vital TABLE 3.5 Key Words Indicating Positive and Negative Polarity Positive Polarity Negative Polarity Acceptable Correct Effective Indicate Most appropriate Most helpful Most likely Most suitable Safest Avoid Contraindicated Incorrect Ineffective Least appropriate, helpful, or likely Unacceptable Unlikely Unrelated Unsafe Violate BOX 3.10 Similar Options Practice Item A 2-year-old client is hospitalized with lymphoma. Which nurs- ing observation, after a parent has left the room, poses the most immediate and serious safety threat to the child and should be removed or changed? 1. Coloring book and crayons left in the crib 2. Placing a doll with movable eyes in the crib 3. Hanging a mobile over the crib 4. Leaving the crib rail halfway down OPTIONS THAT ARE OPPOSITES In both multiple-choice and multiple-response items, look for options that are opposites, such as tachycardia and bradycardia. Either one or both of these options may be incorrect. Focus on eliminating one or both of these op- tions before focusing on the other options. Box 3.11 pro- vides an example of a practice item with options that are opposites. BOX 3.11 Opposite Options Practice Item Two hours after initiating total parenteral nutrition (TPN), a nurse assesses a client and notes diuresis and decreased blood pressure. The nurse recognizes that these signs may indicate that the: 1. glucose content of the TPN solution is too high. 2. TPN solution is infusing too slowly. 3. TPN solution is infusing too rapidly. 4. protein content of the TPN solution is too low. CHAPTER 3 Test-Taking Tips and Strategies 33 GLOBAL OPTIONS A global or umbrella option is one that will be more com- prehensive than the other options and frequently includes information or concepts from one or more of the other op- tions. The three distracter options are usually more specific than the global option. Therefore, the global option will be the correct option. Box 3.12 provides an example of a prac- tice item with a global option. ANSWER: 3 If the TPN solution is infusing too rapidly, hyperosmolar di- uresis occurs from rapid infusion of glucose, which results in a rapid increase in blood glucose and rapid metabolism. It is the rapid infusion of the glucose, rather than the amount of glucose, causing the symptoms. Protein content will not cause diuresis. Test-taking Tip: Note that options 2 and 3 are opposites. Examine these options first to determine if one or both can be eliminated. Focus on the time frames of 2 hours and the information that this is the initial infusion of theTPN.Think about the nutrient content ofTPN solution and which of those nutrients is metabolized quickly. Content Area: Adult Health; Category of Health Alteration: Gastrointestinal Management; Integrated Processes: Nursing Process Analysis; Client Need: Physiological Integrity/ Pharmacological and Parenteral Therapies/Total Parenteral Nutrition; Cognitive Level: Analysis References: Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2008). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing (11th ed., p. 1198). Philadelphia: Lippincott Williams & Wilkins; Wilkinson, J., & Van Leuven, K. (2007). Fundamentals of Nursing: Theory, Concepts and Applications. (Vol. 1, p. 617). Philadelphia, F. A. Davis. ANSWER: 1 Because young children have not fully developed good hy- giene behaviors, transmission of infectious diseases is facili- tated by fecal, oral, and respiratory routes among other children in their play or school group. Although toys are a source of disease transmission, this option is not as inclusive as option 1. The urinary route is less contagious than the fecal route, which transmits Escherichia coli. Option 3 is concerned with disease transmission only from the respiratory route. Test-taking Tip: Note the plural “sources” of infectious disease in the stem and select the option that is most inclusive. Option 1 is the broadest option addressing the various “routes of transmission.” Content Area: Child Health; Category of Health Alteration: Infectious Disease; Integrated Processes: Teaching/Learning; Client Need: Physiological Integrity/Physiological Adaptation/ Infectious Diseases; Cognitive Level: Application Reference: Ball, J., & Bindler, R. (2006). Child Health Nursing: Partnering with Children and Families. (p. 597). Upper Saddle River, NJ: Pearson Education. BOX 3.12 Global Options Practice Item A nurse is teaching day-care providers caring for young children about infectious disease transmission. About which most com- mon sources for disease transmission should the nurse teach the day-care providers? 1. Fecal, oral, and respiratory routes 2. Contact with toys that are shared 3. Urinary, oral, and respiratory secretions 4. Sneezing, coughing, and rubbing a runny nose and then touching others 34 SECTION I Preparing for the NCLEX-RN® DUPLICATE INFORMATION AMONG OPTION ITEMS Some test items are designed so that more than one point or fact is included within each option. For these types of questions, first look for the options with duplicate information and determine if that information is correct or in- correct. If it is incorrect, then you can eliminate all items with the duplicate information. Box 3.13 provides an example of a practice item with duplicate information among answer options. DELEGATION AND ASSIGNMENT ITEMS Most likely, there will be questions that ask you to delegate or assign certain clients or tasks to other health-care person- nel. Read the question thoroughly so that you understand the task or to whom the task is being delegated or assigned. Carefully look at what is being asked and match the skill with the scope of practice of the appropriate caregiver. Use the five rights of delegation: the right task, under the right circumstances, to the right person, with the right direction and communication, and the right supervision and evalua- tion. Remember that registered nurses (RNs) are responsi- ble for assessing, evaluating, teaching, and making deci- sions about client care and that these tasks cannot be delegated. Note that observations, but not assessments, can BOX 3.13 Duplicate Information Among Options Practice Item A client is newly admitted with a diagnosis of left-sided heart failure. On assessment of the client, which findings should a nurse expect? 1. Chest tightness and ascites 2. Dyspnea on exertion and ascites 3. Dyspnea on exertion and crackles 4. Neck vein distention and crackles be delegated. Because the scope of practice varies by state, you should encounter only the universal tasks that can be delegated. Table 3.6 illustrates examples of tasks that may and may not be delegated to unlicensed assistive personnel. NCLEX-RN® questions may also ask you to decide when to notify a physician or other health-care provider. On the NCLEX-RN® examination, the option of notifying the physician may