Saunders Comprehensive Review for the NCLEX-RN Examination

BOX 1-2 Safe and Effective Care Environment Management of Care The nurse has received the client assignment for the day. Which client should the nurse assess first? 1. The client who needs to receive subcutaneous insulin before breakfast 2. The client who has a nasogastric tube attached to intermit- tent suction 3. The client who is 2 days postoperative and is complaining of incisional pain 4. The client who has a blood glucose level of 50 mg/dL (2.8 mmol/ L) and complaints of blurred vision Answer: 4 This question addresses the subcategory Management of Care in the Client Needs categorySafe and Effective Care Envi- ronment. Note the strategic word, first, so you need to estab- lish priorities by comparing the needs of each client and deciding which need is urgent. The client described in the cor- rect option has a low blood glucose level and symptoms reflec- tive of hypoglycemia. This client should be assessed first so that treatment can be implemented. Although the clients in options 1, 2, and 3 have needs that require assessment, their assessments can wait until the client in the correct option is stabilized. Safety and Infection Control The nurse prepares to care for a client on contact precautions who has a hospital-acquired infection caused by methicillin- resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheos- tomy attached to a mechanical ventilator, which requires fre- quent suctioning. The nurse should assemble which necessary protective items before entering the client’s room? 1. Gloves and gown 2. Gloves and face shield 3. Gloves, gown, and face shield 4. Gloves, gown, and shoe protectors Answer: 3 This question addresses the subcategory Safety and Infection Control in the Client Needs category Safe and Effective Care Environment. It addresses content related to protecting one- self from contracting an infection and requires that you con- sider the methods of possible transmission of infection, based on the client’s condition. Because splashes of infective material can occur during the wound irrigation or suctioning of the tracheostomy, option 3 is correct. Health Promotion and Maintenance The Health Promotion and Maintenance category (6% to 12% of questions) addresses the principles related to growth and development. According to the NCSBN, this Client Needs category also addresses content required to assist the client, family members, and signif- icant others to prevent health problems; to recognize alterations in health; and to develop health practices that promote and support wellness. See Box 1-3 for an example of a question in this Client Needs category. CHAPTER 1 The NCLEX-RN® Examination 5 BOX 1-3 Health Promotion and Maintenance The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this age? 1. Puzzle 2. Toysoldiers 3. Large stacking blocks 4. A card game with large pictures Answer: 3 This question addresses the Client Needs category Health Promotion and Maintenance and specifically relates to the principles of growth and development of a toddler. Note the strategic word, best. Toddlers like to master activities indepen- dently, such as stacking blocks. Because toddlers do not have the developmentalabilityto determine what could be harmful, toys that are safe need to be provided. A puzzle and toy sol- diers provide objects that can be placed in the mouth and maybe harmful for a toddler. Acard game with large pictures may require cooperative play, which is more appropriate for a school-age child. Psychosocial Integrity The Psychosocial Integrity category (6% to 12% of ques- tions) addresses content required to promote and sup- port the ability of the client, client’s family, and client’s significant other to cope, adapt, and problem- solve during stressful events. The NCSBN also indicates that this Client Needs category addresses the emotional, mental, and social well-being of the client, family, or sig- nificant other, and care for the client with an acute or chronic mental illness. See Box 1-4 for an example of a question in this Client Needs category. Physiological Integrity The Physiological Integrity category includes 4 subcat- egories: Basic Care and Comfort, Pharmacological and Parenteral Therapies, Reduction of Risk Potential, and BOX 1-4 Psychosocial Integrity A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which client statement indicates an understanding of this stress reduction measure? 1. “This will help only if I play music at the same time.” 2. “This will work for me only if I am alone in a quiet area.” 3. “IneedtodothisonlywhenIliedownincaseIfallasleep.” 4. “The best thing about this is that I can use it anywhere, anytime.” Answer: 4 This question addresses the Client Needs category Psychoso- cial Integrity and the content addresses coping mechanisms. Guided imagery involves the client creating an image in the mind, concentrating on the image, and gradually becoming less aware of the offending stimulus. It can be done anytime and anywhere; some clients may use other relaxation tech- niques or play music with it. 6 UNIT I NCLEX-RN® Exam Preparation Physiological Adaptation. The NCSBN describes these subcategories as follows. Basic Care and Comfort (6% to 12% of questions) addresses content for providing comfort and assistance to the client in the performance of activities of daily living. Pharmacological and Par- enteral Therapies (12% to 18% of questions) addresses content for administering medications and parenteral therapies such as intravenous therapies and parenteral nutrition, and administering blood and blood products. Reduction of Risk Potential (9% to 15% of questions) addresses content for preventing complications or health problems related to the client’s condition or BOX 1-5 Physiological Integrity Basic Care and Comfort Aclient with Parkinson’s disease develops akinesia while ambu- lating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem? 1. Use a wheelchair to move around. 2. Stand erect and use a cane to ambulate. 3. Keep the feet close together while ambulating and use a walker. 4. Consciously think about walking over imaginary lines on the floor. Answer: 4 This question addresses the subcategory Basic Care and Com- fort in the Client Needs category Physiological Integrity, and addresses client mobility and promoting assistance in an activ- ityofdailyliving to maintain safety. Clients with Parkinson’s dis- ease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these clients imagine lines on the floor to walk over can keep them moving forward while remaining safe. Pharmacological and Parenteral Therapies The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity? 1. Anorexia 2. Facial pain 3. Photophobia 4. Yellow color perception Answer: 1 This question addresses the subcategory Pharmacological and Parenteral Therapies in the Client Needs category Physiological Integrity. Note the strategic word, early. Digoxin is a cardiac gly- coside that is used to manage and treat heart failure and to con- trol ventricular rates in clients with atrial fibrillation. The most common early manifestations of toxicity include gastrointesti- nal disturbances such as anorexia, nausea, and vomiting. Neu- rological abnormalities can also occur earlyand include fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares. Facial pain, personality changes, and ocular distur- bances (photophobia, diplopia, light flashes, halos around bright objects, yellow or green color perception) are also signs of toxicity, but are not early signs. any prescribed treatments or procedures. Physiological Adaptation (11% to 17% of questions) addresses content for providing care to clients with acute, chronic, or life-threatening conditions. See Box 1-5 for examples of questions in this Client Needs category. Integrated Processes The NCSBN identifies 5 processes in the test plan that are fundamental to the practice of nursing. These processes are incorporated throughout the major categories of Cli- ent Needs. The Integrated Process subcategories are Car- ing, Communication and Documentation, Nursing Reduction of Risk Potential A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. The nurse should imple- ment which action to prepare the client for this test? 1. 2. 3. 4. Shave the groin for insertion of a femoral catheter. Remove all metal-containing objects from the client. KeeptheclientNPO(nilperos;nothingbymouth)for6hours before the test. Instruct the client in inhalation techniques for the adminis- tration of the radioisotope. Answer: 2 This question addresses the subcategory Reduction of Risk Potential in the Client Needs category Physiological Integrity, and the nurse’s responsibilities in preparing the client for the diagnostic test. In an MRI study, radiofrequencypulses in a mag- netic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, and watches, should be removed. In addition, a historyshould be taken to ascertain whether the client has any internal metallic devices, such as orthopedic hardware, pacemakers, or shrapnel. NPO status is not necessary for an MRI study of the head. The groin may be shaved for an angio- gram, and inhalation of the radioisotope may be prescribed with other types of scans but is not a part of the procedures for an MRI. Physiological Adaptation A client with renal insufficiency has a magnesium level of 3.5 mEq/ L (1.75 mmol/ L). On the basis of this laboratory result, the nurse interprets which sign as significant? 1. Hyperpnea 2. Drowsiness 3. Hypertension 4. Physical hyperactivity Answer: 2 This question addresses the subcategory Physiological Adap- tation in the Client Needs category Physiological Integrity. It addresses an alteration in body systems. The normal magnesium level is 1.5 to 2.5mEq/L(0.75 to 1.25mmol/L). Amagnesium levelof3.5mEq/L(1.75mmol/L) indicates hyper- magnesemia. Neurological manifestations begin to occur when magnesium levels are elevated and are noted as symptoms of neurological depression, such as drowsiness, sedation, leth- argy, respiratory depression, muscle weakness, and areflexia. Bradycardia and hypotension also occur. BOX 1-6 Integrated Processes A client is scheduled for angioplasty. The client says to the nurse, “I’m so afraid that it will hurt and will make me worse off than I am.” Which response by the nurse is therapeutic? 1. “Can you tell me what you understand about the procedure?” 2. “Your fears are a sign that you really should have this procedure.” 3. “Those are very normal fears, but please be assured that everything will be okay.” 4. “Try not to worry. This is a well-known and easy procedure for the health care provider.” Answer: 1 This question addresses the subcategory Caring in the cate- gory Integrated Processes. The correct option is a therapeutic communication technique that explores the client’s feelings, determines the level of client understanding about the proce- dure, and displays caring. Option 2 demeans the client and does not encourage further sharing by the client. Option 3 does not address the client’s fears, provides false reassurance, and puts the client’s feelings on hold. Option 4 diminishes the client’s feelings bydirecting attention awayfrom the client and toward the health care provider’s importance. Process(Assessment,Analysis,Planning,Implementation, and Evaluation), Culture and Spirituality, and Teaching and Learning. See Box 1-6 for an example of a question that incorporates the Integrated Process of Caring. Types of Questions on the Examination The types of questions that may be administered on the examination include multiple-choice; fill-in-the-blank; multiple-response; ordered-response (also known as drag and drop); questions that contain a figure, chart/exhibit, or graphic option item; and audio or video item formats. Some questions may require you to use the mouse and cursor on the computer. For example, you may be pre- sented with a picture that displays the arterial vessels of an adult client. In this picture, you may be asked to “point and click” (using the mouse) on the area (hot spot) where the dorsalis pedis pulse could be felt. In all types of ques- tions, the answer is scored as either right or wrong. Credit is not given for a partially correct answer. In addition, all question types may include pictures, graphics, tables, charts, sound, or video. The NCSBN provides specific directions for you to follow with all question types to guide you in your process of testing. Be sure to read these directions as they appear on the computer screen. Exam- ples of some of these types of questions are noted in this chapter. All question types are provided in this book and on the accompanying Evolve site. Multiple-Choice Questions Many of the questions that you will be asked to answer will be in the multiple-choice format. These questions CHAPTER 1 The NCLEX-RN® Examination 7 provide you with data about a client situation and 4 answers, or options. Fill-in-the-Blank Questions Fill-in-the-blank questions may ask you to perform a medication calculation, determine an intravenous flow rate, or calculate an intake or output record on a client. You will need to type only a number (your answer) in the answer box. If the question requires rounding the answer, this needs to be performed at the end of the cal- culation. The rules for rounding an answer are described in the tutorial provided by the NCSBN, and are also pro- vided in the specific question on the computer screen. In addition, you must type in a decimal point if necessary. See Box 1-7 for an example. Multiple-Response Questions For a multiple-response question, you will be asked to select or check all of the options, such as nursing interven- tions, that relate to the information in the question. In these question types, there may be 2 or more correct answers. No partial credit is given for correct selections. You need to do exactly as the question asks, which will be to select all of the options that apply. See Box 1-8 for an example. Ordered-Response Questions In this type of question, you will be asked to use the com- puter mouse to drag and drop your nursing actions in order of priority. Information will be presented in a question and, based on the data, you need to determine what you will do first, second, third, and so forth. The unordered options will be located in boxes on the left side of the screen, and you need to move all options in order of priority to ordered-response boxes on the BOX 1-7 Fill-in-the-Blank Question A prescription reads: acetaminophen liquid, 650 mg orally every 4 hours PRN for pain. The medication label reads: 500 mg/15mL. The nurse prepares how many milliliters to administer 1dose? Fill in the blank. Record your answer using one decimal place. Answer: 19.5 mL Formula: Desired Âvolume1⁄4mL Available 650 mg 15 mL1⁄4 19:5 mL 500mg In this question, you need to use the formula for calculat- ing a medication dose. When the dose is determined, you will need to type your numeric answer in the answer box. Always follow the specific directions noted on the computer screen. Also, remember that there will be an on-screen calculator on the computer for your use. 8 UNIT I NCLEX-RN® Exam Preparation BOX 1-8 Multiple-Response Question The emergency department nurse is caring for a child sus- pected of acute epiglottitis. Which interventions apply in the care of the child? Select all that apply. 1. Obtain a throat culture. 2. Ensure a patent airway. 3. Prepare the child for a chest x-ray. 4. Maintain the child in a supine position. 5. Obtain a pediatric-size tracheostomy tray. 6. Place the child on an oxygen saturation monitor. In a multiple-response question, you will be asked to select or check all of the options, such as interventions, that relate to the information in the question. To answer this question, recall that acute epiglottitis is a serious obstructive inflamma- toryprocess that requires immediate intervention and that air- way patency is a priority. Examination of the throat with a tongue depressor or attempting to obtain a throat culture is contraindicated because the examination can precipitate fur- ther obstruction. A lateral neck and chest x-ray is obtained to determine the degree of obstruction, if present. To reduce respiratory distress, the child should sit upright. The child is placed on an oxygen saturation monitor to monitor oxygena- tion status. Tracheostomy and intubation may be necessary if respiratory distress is severe. Remember to follow the specific directions given on the computer screen. right side of the screen. Specific directions for moving the options are provided with the question. See Figure 1-1 for an example. Examples of this question type are located on the accompanying Evolve site. Figure Questions Aquestion with a picture or graphic will ask you to answer the question based on the picture or graphic. The ques- tion could contain a chart, a table, or a figure or illustra- t i o n . Yo u a l s o m a y b e a s k e d t o u s e t h e c o m p u t e r m o u s e t o point and click on a specific area in the visual. Afigure or illustration may appear in any type of question, including a multiple-choice question. See Box 1-9 for an example. Chart/Exhibit Questions In this type of question, you will be presented with a problem and a chart or exhibit. You will be provided with 3 tabs or buttons that you need to click to obtain the information needed to answer the question. A prompt or message will appear that will indicate the need to click on a tab or button. See Box 1-10 for an example. Graphic Option Questions In this type of question, the option selections will be pic- tures rather than text. Each option will be preceded by a circle, and you will need to use the computer mouse to click in the circle that represents your answer choice. See Box 1-11 for an example. Audio Questions Au d i o q u e s t i o n s w i l l r e q u i r e l i s t e n i n g t o a s o u n d t o a n s w e r the question. These questions will prompt you to use the headset provided and to click on the sound icon. You will be able to click on the volume button to adjust the volume to your comfort level, and you will be able to listen to the FIGURE 1-1 Example of an ordered-response question. CHAPTER 1 The NCLEX-RN® Examination 9 BOX 1-9 Figure Question A client who experienced a myocardial infarction is being monitored via cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor (refer to figure) and immediately takes which action? 1. Takes the client’s blood pressure 2. Initiates cardiopulmonary resuscitation (CPR) 3. Places a nitroglycerin tablet under the client’s tongue 4. Continues to monitor the client and then contacts the health care provider (HCP) Answer: 2 This question requires you to identify the cardiac rhythm, and then determine the priority nursing action. Note the strategic word, immediately. This cardiac rhythm identifies a coarse ventricular fibrillation (VF). The goals of treatment are to terminate VF promptly and to convert it to an organized rhythm. The HCP or an Advanced Cardiac Life Support (ACLS)–qualified nurse must immediately defibrillate the client. If a defibrillator is not readily available, CPR is initiated until the defibrillator arrives. Options 1, 3, and 4 are incorrect actions and delay life-saving treatment. BOX 1-10 History and physical Item 1: Has renal calculi Item 2: Had throm- bophlebitis 1 year ago Client’s Chart Medications Item 3: Multivita- min orally daily Diagnostic results Item 4: Electrocar- diogram normal Chart/ Exhibit Question BOX 1-11 Graphic Options Question The nurse should place the client in which position to admin- ister an enema? (Refer to the figures in 1 to 4.) 1. 2. 3. 4. Answer: 2 This question requires you to select the picture that represents your answer choice. To administer an enema, the nurse assists the client into the left side-lying (Sims’) position with the right knee flexed. This position allows the enema solution to flow downward by gravity along the natural curve of the sig- moid colon and rectum, improving the retention of solution. Option 1 is a prone position. Option 3 is a dorsal recumbent position. Option 4 is a supine position. Video Questions Video questions will require viewing of an animation or video clip to answer the question. These questions will prompt you to click on the video icon. There may be sound associated with the animation and video, in which case you will be prompted to use the headset. The nurse reviews the history and physical examination documented in the medical record of a client requesting a pre- scription for oral contraceptives. The nurse determines that oral contraceptives are contraindicated because of which documented item? Refer to chart. Answer: 2 This chart/exhibit question provides you with data from the cli- ent’s medical record and asks you to identify the item that is a contraindication to the use of oral contraceptives. Oral contra- ceptives are contraindicated in women with a history of any of the following: thrombophlebitis and thromboembolic disor- ders, cardiovascular or cerebrovascular diseases (including stroke), any estrogen-dependent cancer or breast cancer, benign or malignant liver tumors, impaired liver function, hypertension, and diabetes mellitus with vascular involvement. Adverse effects of oral contraceptives include increased risk of superficial and deep venous thrombosis, pulmonaryembolism, thrombotic stroke (or other types of strokes), myocardial infarc- tion, and accelerations of preexisting breast tumors. sound as many times as necessary. Content examples include, but are not limited to, various lung sounds, heart sounds, or bowel sounds. Examples of this question type are located on the accompanying Evolve site (Fig. 1-2). 10 UNIT I NCLEX-RN® Exam Preparation Content examples include, but are not limited to, assess- ment techniques, nursing procedures, or communica- tion skills. Examples of this question type are located on the accompanying Evolve site (Fig. 1-3). Registering to Take the Examination It is important to obtain an NCLEXExamination Candi- date Bulletin from the NCSBN Web site at . org because this bulletin provides all of the information you need to register for and schedule your examination. It also provides you with Web site and telephone informa- tion for NCLEXexamination contacts. The initial step in the registration process is to submit an application to the state board of nursing in the state in which you intend to obtain licensure. You need to obtain information from the board of nursing regarding the specific registration process because the process may vary from state to state. Then, use the NCLEXExamination Candidate Bulletin as your guide to complete the registration process. Following the registration instructions and complet- ing the registration forms precisely and accurately are important. Registration forms not properly complet- ed or not accompanied by the proper fees in the required method of payment will be returned to you and will delay testing. You must pay a fee for taking the examination; you also may have to pay additional fees to the board of nursing in the state in which you are applying. Authorization to Test Form and Scheduling an Appointment Once you are eligible to test, you will receive an Autho- rization to Test (ATT) form. You cannot make an appointment until you receive an ATT form. Note the validity dates on the ATT form, and schedule a testing date and time before the expiration date on the ATT form. The NCLEX Examination Candidate Bulletin pro- vides you with the directions for scheduling an appoint- ment and you do not have to take the examination in the same state in which you are seeking licensure. The ATT form contains important information, including your test authorization number, candidate identification number, and validity date. You need to take your ATT form to the testing center on the day of your examination. You will not be admitted to the exam- ination if you do not have it. Changing Your Appointment If for any reason you need to change your appointment to test, you can make the change on the candidate Web site or bycallingcandidateservices.Referto theNCLEXExamina- tion Candidate Bulletin for this contact information and other important procedures for canceling and changing an appointment. If you fail to arrive for the examination FIGURE 1-2 Example of an audio question. or fail to cancel your appointment to test without provid- ing appropriate notice, you will forfeit your examination fee and your ATT form will be invalidated. This informa- tion will be reported to the board of nursing in the state in which you have applied for licensure, and you will be required to register and pay the testing fees again. Day of the Examination It is important that you arrive at the testing center at least 30 minutes before the test is scheduled. If you arrive late for the scheduled testing appointment, you may be required to forfeit your examination appointment. If it is necessary to forfeit your appointment, you will need to reregister for the examination and pay an additional fee. The board of nursing will be notified that you did not take the test. A few days before your scheduled date of testing, take the time to drive to the testing center to determine its exact location, the length of time required to arrive at that des- tination, and any potential obstacles that might delay you, such as road construction, traffic, or parking sites. In addition to the ATT form, you must have proper identification (ID) such as a U.S. driver’s license, pass- port, U.S. state ID, or U.S. military ID to be admitted to take the examination. All acceptable identification must be valid and not expired and contain a photograph and signature (in English). In addition, the first and last names on the ID must match the ATTform. According to the NCSBN guidelines, any name discrepancies require legal documentation, such as a marriage license, divorce decree, or court action legal name change. Testing Accommodations If you require testing accommodations, you should con- tact the board of nursing before submitting a registration form.Theboard ofnursingwillprovidetheproceduresfor the request. The board of nursing must authorize testing accommodations. Following board of nursing approval, the NCSBN reviews the requested accommodations and must approve the request. If the request is approved, the candidate will be notified and provided the procedure for registering for and scheduling the examination. Testing Center The testing center is designed to ensure complete security of the testing process. Strict candidate identification requirements have been established. You will be asked to read the rules related to testing. A digital fingerprint and palm vein print will be taken. Adigital signature and pho- tograph will also be taken at the testing center. These iden- tity confirmations will accompany the NCLEX exam results.In addition,ifyou leavethetestingroom foranyrea- son, you may be required to perform these identity confir- mation procedures again to be readmitted to the room. Personal belongings are not allowed in the testing room; all electronic devices must be placed in a sealable FIGURE 1-3 Example of a video question. CHAPTER 1 The NCLEX-RN® Examination 11 12 UNIT I NCLEX-RN® Exam Preparation bag provided by the test administrator and kept in a locker. Any evidence of tampering with the bag could result in an incident and a result cancellation. A locker and locker key will be provided for you; however, storage space is limited, so you must plan accordingly. In addi- tion, the testing center will not assume responsibility for your personal belongings. The testing waiting areas are generally small; friends or family members who accom- pany you are not permitted to wait in the testing center while you are taking the examination. Once you have completed the admission process, the test administrator will escort you to the assigned com- puter. You will be seated at an individual workspace area that includes computer equipment, appropriate lighting, an erasable note board, and a marker. No items, including unauthorized scratch paper, are allowed into the testing room. Eating, drinking, or the use of tobacco is not allowed in the testing room. You will be observed at all times by the test administrator while taking the examina- tion.In addition,video and audio recordingsofalltestses- sions are made. The testing center has no control over the soundsmadebytypingon thecomputerbyothers.Ifthese soundsaredistracting,raiseyourhand to summon thetest administrator. Earplugs are available on request. You must follow the directions given by the testing cen- ter staff and must remain seated during the test except when authorized to leave. If you think that you have a problem with the computer, need a clean note board, need to take a break, or need the test administrator for any rea- son, you must raise your hand. You are also encouraged to access the NCSBN candidate Web site to obtain additional information about the physical environment of the testing center and to view a virtual tour of the testing center. Testing Time The maximum testing time is 6 hours; this period includes the tutorial, the sample items, all breaks, and the examination. All breaks are optional. The first optional break will be offered after 2 hours of testing. The second optional break is offered after 3.5 hours of testing. Remember that all breaks count against testing time. If you take a break, you must leave the testing room and, when you return, you may be required to perform identity confirmation procedures to be readmitted. Length of the Examination The minimum number of questions that you will need to answer is 75. Of these 75 questions, 60 will be operational (scored) questions and 15 will be pretest (unscored) questions. The maximum number of questions in the test is 265. Fifteen of the total number of questions that you need to answer will be pretest (unscored) questions. The pretest questions are questions that may be pre- sented as scored questions on future examinations. These pretest questions are not identified as such. In other words, you do not know which questions are the pretest (unscored) questions; however, these pretest (unscored) questions will be administered among the first 75 questions in the test. Pass-or-Fail Decisions All examination questions are categorized by test plan area and level of difficulty. This is an important point to keep in mind when you consider how the computer makes a pass-or-fail decision because a pass-or-fail decision is not based on a percentage of correctly answered questions. The NCSBN indicates that a pass-or-fail decision is governed by 3 different scenarios. The first scenario is the 95% Confidence Interval Rule, in which the com- puter stops administering test questions when it is 95% certain that the test-taker’s ability is clearly above the passing standard or clearly below the passing stan- dard. The second scenario is known as the Maximum- Length Exam, in which the final ability estimate of the test-taker is considered. If the final ability estimate is above the passing standard, the test-taker passes; if it is below the passing standard, the test-taker fails. The third scenario is the Run-Out-Of-Time (R.O.O.T) Rule. If the examination ends because the test-taker ran out of time, the computer may not have enough informa- tion with 95% certainty to make a clear pass-or-fail deci- sion. If this is the case, the computer will review the test-taker’s performance during testing. If the test-taker hasnotansweredtheminimum numberofrequiredques- tions, the test-taker fails. If the test-taker’s ability estimate was consistently above the passing standard on the last 60 questions, the test-taker passes. If the test-taker’s ability estimate falls below the passing standard, even once, the test-taker fails. Additional information about pass- or-fail decisions can be found in the NCLEXExamination Candidate Bulletin located at . Completing the Examination When the examination has ended, you will complete a brief computer-delivered questionnaire about your testing experience. After you complete this question- naire, you need to raise your hand to summon the test administrator. The test administrator will collect and inventory all note boards and then permit you to leave. Processing Results Every computerized examination is scored twice, once by the computer at the testing center and again after the examination is transmitted to the test scoring center. No results are released at the testing center; testing center staff do not have access to examination results. The board of nursing receives your result and your result will be mailed to you approximately 1 month after you take the examination. In some states, an unofficial result can be obtained via the Quick Results Service 2 business days after taking the examination. There is a fee for this service and information about obtaining your NCLEXresult by this method can be obtained on the NCSBN Web site under candidate services. Candidate Performance Report Acandidate performance report is provided to a test-taker who failed the examination. This report provides the test- taker with information about her or his strengths and weaknesses in relation to the test plan framework and pro- vides a guide for studying and retaking the examination. If a retake is necessary, the candidate must wait 45 to 90 days between examination administration, depending on state procedures. Test-takers should refer to the state board of nursing in the state in which licensure is sought for proce- duresregardingwhen theexamination can betaken again. Interstate Endorsement Because the NCLEX-RN examination is a national exam- ination, you can apply to take the examination in any state. When licensure is received, you can apply for inter- state endorsement, which is obtaining another license in another state to practice nursing in that state. The pro- cedures and requirements for interstate endorsement may vary from state to state, and these procedures can be obtained from the state board of nursing in the state in which endorsement is sought. Nurse Licensure Compact It may be possible to practice nursing in another state under the mutual recognition model of nursing licensure if the state has enacted a Nurse Licensure Compact. To obtain information about the Nurse Licensure Compact and the states that are part of this interstate compact, access the NCSBN Web site at . The Foreign-Educated Nurse An important first step in the process of obtaining infor- mation about becoming a registered nurse in the United States is to access the NCSBN Web site at http://www. and obtain information provided for interna- tional nurses in the NCLEX Web site link. The NCSBN provides information about some of the documents you need to obtain as an international nurse seeking licensure in the United States and about credentialing agencies. Refer to Box 1-12 for a listing of some of these BOX 1-12 Foreign-Educated Nurse: Some Documents Needed to Obtain Licensure CHAPTER 1 The NCLEX-RN® Examination 13 1. Proof of citizenship or lawful alien status 2. Work visa 3. VisaScreen certificate 4. Commission on Graduates of Foreign Nursing Schools (CGFNS) certificate 5. Criminal background check documents 6. Officialtranscriptsofeducationalcredentialssentdirectly to credentialing agency or board of nursing from home country school of nursing 7. Validation of a comparable nursing education as that pro- vided in U.S. nursing programs; this mayinclude theoretical instruction and clinicalpractice in a varietyofnursing areas, including, but not limited to, medical nursing, surgical nurs- ing, pediatric nursing, maternityand newborn nursing, com- munityandpublichealthnursing,andmentalhealthnursing 8. Validation of safe professional nursing practice in home country 9. Copy of nursing license or diploma or both 10. Proof of proficiency in the English language 11. Photograph(s) 12. Social Security number 13. Application and fees documents. The NCSBN also provides information regarding the requirements for education and English proficiency, and immigration requirements such as visas and VisaScreen. You are encouraged to access the NCSBN Web site to obtain the most current information about seeking licensure as a registered nurse in the United States. An important factor to consider as you pursue this process is that some requirements may vary from state to state. You need to contact the board of nursing in the state in which you are planning to obtain licensure to determine the specific requirements and documents that you need to submit. Boards of nursing can decide either to use a credential- ing agency to evaluate your documents or to review your documents at the specific state board, known as in-house evaluation. When you contact the board of nursing in the state in which you intend to work as a nurse, inform them that you were educated outside of the United States and ask that they send you an application to apply for licensure by examination. Be sure to specify that you are applying for registered nurse (RN) licensure. You should also ask about the specific documents needed to become eligible to take the NCLEXexam. You can obtain contact informa- tion for each state board of nursing through the NCSBN Web site at . In addition, you can write to the NCSBN regarding the NCLEX exam. The address is 111 East Wacker Drive, Suite 2900, Chicago, IL 60601. The telephone number for the NCSBN is ; international telephone is ; the fax number is . CHAPTER 2 Pathways to Success Laurent W. Valliere, BS, DD The Pyramid to Success List It is time to create the “List.” The List is your set of short- term and long-term goals. Begin by developing the goals that you wish to accomplish today, tomorrow, over the next month, and in the future. Allow yourself the oppor- tunity to list all that is flowing from your mind. Write your goals in your personal journal. When the List is complete, put it away for 2 or 3 days. After that time, retrieve and review the List and begin the process of planning to prepare for the NCLEX-RN exam. Plan for Preparation Now that you have the List in order, look at the goals that relate to studying for the licensing exam. The first task is to decide what study pattern works best for you. Think about what has worked most successfully for you in the past. Questions that must be addressed to develop your plan for study are listed in Box 2-2. The plan must include a schedule. Use a calendar to plan and document the daily times and nursing content areas for your study sessions. Establish a realistic sched- ule that includes your daily, weekly, and future goals, and stick to your plan of study. This consistency will provide advantages to you and the people supporting you. You will develop a rhythm that can enhance your retention and positive momentum. The people who are supporting you will share this rhythm and be able to schedule their activities and lives better when you are consistent with your study schedule. The length of the study session depends on your abil- ity to focus and concentrate. You need to think about quality rather than quantity when you are deciding on a realistic amount of time for each session. Plan to sched- ule at least 2 hours of quality study time daily. If you can spend more than 2 hours, by all means do so. You may ask, “What do you mean by quality study time?” Quality study time means spending uninter- rupted quiet time at your study session. This may mean that you have to isolate yourself for these study sessions. Think again about what has worked for you during nurs- ing school when you studied for examinations; select a study place that has worked for you in the past. If you 14 Preparing to take the NCLEX-RN® examination can pro- duce a great deal of anxiety. You may be thinking that this exam is the most important one you will ever have to take and that it reflects the culmination of everything you have worked so hard for. This is an important exam- ination because receiving your nursing license means that you can begin your career as a registered nurse. Your success on this exam involves getting rid of all thoughts that allow this examination to appear overwhelming and intimidating. Such thoughts can take complete control over your destiny. A strong positive attitude, a structured plan for preparation, and maintaining con- trol in your pathway to success ensure reaching the peak of the Pyramid to Success (Fig. 2-1). Pathways to Success (Box 2-1) Foundation The foundation of pathways to success begins with a strong positive attitude, the belief that you will achieve success, and developing control. It also includes develop- ing a list of your personal short-term and long-term goals and a plan for preparation. Without these components, your pathway to success leads to nowhere and has no endpoint. You will expend energy and valuable time in your journey, lack control over where you are heading, and experience exhaustion without any accomplishment. Where do you start? To begin, find a location that offers solitude. Sit or lie in a comfortable position, close your eyes, relax, inhale deeply, hold your breath to a count of 4, exhale slowly, and, again, relax. Repeat this breathing exercise several times until you feel relaxed, free from anxiety, and in control of your destiny. Allow your mind to become void of all mind chatter; now you are in control and your mind’s eye can see for miles. Next, reflect on all that you have accomplished and the path that brought you to where you are today. Keep a journal of your reflections as you plan the order of your journey through the Pyramid to Success. Registered Nurse! Control Structured study plan Strong positive attitude FIGURE 2-1 Pyramid to Success. Pathways to Success Maintaining a strong positive attitude Thinking about short-term and long-term realistic goals Developing a plan for preparation Maintaining control Li s t Writing short-term and long-term realistic goals in a journal Plan for Preparation Developing a study plan and schedule Deciding on the place to study Balancing personal and work obligations with the study schedule Sharing the study schedule and personal needs with others Implementing the study plan Positive Pampering Planning time for exercise and fun activities Establishing healthy eating habits Including activities in the schedule that provide positive men- tal stimulation Final Preparation Reviewing and identifying goals achieved Remaining focused to complete the plan of study Writing down the date and time of the examination and post- ing it next to your name with the letters “RN” following, and the word “YES!” Planning a test drive to the testing center Engaging in relaxing activities on the day before the examination Day of the Examination Grooming yourself for success Eating a nutritious breakfast Maintaining a confident and positive attitude Maintaining control—breathe and focus Meeting the challenges of the day Reaching the peak of the Pyramid to Success CHAPTER 2 Pathways to Success 15 BOX 2-2 Developing a Plan for Study Do I work better alone or in a study group? If I work best in a group, how many study partners should I have? Who are these study partners? How long should my study sessions last? Does the time of day that I study make a difference? Do I retain more if I study in the morning? How does my work schedule affect my study pattern? How do I balance my family obligations with my need to study? Do I have a comfortable study area at home or should I find another environment that is conducive to my study needs? have a special study room at home that you have always used, plan your study sessions in that special room. If you have always studied at a library, plan your study ses- sions at the library. Sometimes it is difficult to balance your study time with your family obligations and possi- bly a work schedule, but, if you can, plan your study time when you know that you will be at home alone. Try to eliminate anything that may be distracting during your study time. Silence your cellphone appropriately so that you will not be disturbed. If you have small children, plan your study time during their nap time or during their school hours. Your plan must include how you will manage your study needs with your other obligations. Your family and friends are key players in your life and are going to become part of your Pyramid to Success. After you have established your study needs, communicate your needs and the importance of your study plan to your family and friends. A difficult part of the plan may be how to deal with family members and friends who choose not to partici- pate in your plan for success. For example, what do you do if a friend asks you to go to a movie and it is your scheduled study time? Your friend may say, “Take some time off. You have plenty of time to study. Study later when we get back!” You are faced with a decision. You must weigh all factors carefully. You must keep your goals in mind and remember that your need for positive momentum is critical. Your decision may not be an easy one, but it must be one that will ensure that your goal of becoming a registered nurse is achieved. Positive Pampering Positive pampering means that you must continue to care for yourself holistically. Positive momentum can be maintained only if you are properly balanced. Proper exercise, diet, and positive mental stimulation are crucial to achieving your goal of becoming a registered nurse. Just as you have developed a schedule for study, you should have a schedule that includes fun and physical BOX 2-1 Foundation 16 UNIT I NCLEX-RN® Exam Preparation activity. It is your choice—aerobics, walking, weight lift- ing, bowling, or whatever makes you feel good about yourself. Time spent away from the hard study schedule and devoted to some fun and physical exercise pays you back a hundredfold. You will be more energetic with a schedule that includes these activities. Establish healthy eating habits. Be sure to drink plenty of water, which will flush and clean your body cells. Stay away from fatty foods because they slow you down. Eat lighter meals and eat more frequently. Include complex carbohydrates such as oatmeal or whole grain foods in your diet for energy, and be careful not to include too much caffeine in your daily diet. Take the time to pamper yourself with activities that make you feel even better about who you are. Make din- ner reservations at your favorite restaurant with some- one who is special and is supporting your goal. Take walks in a place that has a particular tranquility that enables you to reflect on the positive momentum that you have achieved and maintained. Whatever it is, wher- ever it takes you, allow yourself the time to do some pos- itive pampering. Final Preparation You have established the foundation of your Pyramid to Success. You have developed your list of goals and your study plan, and you have maintained your positive momentum. You are moving forward, and in control. When you receive your date and time for the NCLEX- RN examination, you may immediately think, “I am not ready!” Stop! Reflect on all you have achieved. Think aboutyourgoalachievementandtheorganizationofthe positive life momentum with which you have sur- rounded yourself. Think about all of the people who love and support your effort to become a registered nurse. Believe that the challenge that awaits you is one that you have successfully prepared for and will lead you to your goal of becoming a registered nurse. Take a deep breath and organize the remaining days so that they support your educational and personal needs. Support your positive momentum with a visual technique. Write your name in large letters, and write the letters “RN” after it. Post 1 or more of these visual reinforcements in areas that you frequent. This is a visual motivational technique that works for many nursing graduates preparing for this examination. It is imperative that you not fall into the trap of expecting too much of yourself. The idea of perfection must not drive you to a point that causes your positive momentum to falter. You must believe and stay focused on your goal. The date and time are at hand. Write the date and time, and underneath write the word “YES!” Post this next to your name plus “RN.” Ensure that you have command over how to get to the testing center. A test run is a must. Time the drive, and allow for road construction or whatever might occur to slow traffic down. On the test run, when you arrive at the test facility, walk into it and become familiar with the lobby and the surroundings. This may help to alleviate some of the peripheral nervousness associated with entering an unknown building. Remember that you must do whatever it takes to keep yourself in control. If familiarizing yourself with the facility will help you to maintain positive momentum, by all means be sure to do so. It is time to check your study plan and make the nec- essary adjustments now that a firm date and time are set. Adjust your review so that your study plan ends 2 days before the examination. The mind is like a muscle. If it is overworked, it has no strength or stamina. Your strat- egy is to rest the body and mind on the day before the examination.Yourstrategyistostayincontrolandallow yourself the opportunity to be absolutely fresh and attentive on the day of the examination. This will help you to control the nervousness that is natural, achieve the clear thought processes required, and feel confident that you have done all that is necessary to prepare for and conquer this challenge. The day before the examina- tion is to be one of pleasure. Treat yourself to what you enjoy the most. Relax! Take a deep breath, hold to a count of 4, and exhale slowly. You have prepared yourself well for the challenge of tomorrow. Allow yourself a restful night’s sleep, and wake up on the day of the examination know- ing that you are absolutely prepared to succeed. Look at your name with “RN” after it and the word “YES!” Day of the Examination (Box 2-3) Wake up believing in yourself and that all you have accomplished is about to propel you to the professional level of registered nurse. Allow yourself plenty of time, eat a nutritious breakfast, and groom yourself for suc- cess. You are ready to meet the challenges of the day and overcome any obstacle that may face you. Today will soon be history, and tomorrow will bring you the enve- lope on which you read your name with the words “Reg- istered Nurse” after it. Be proud and confident of your achievements. You have worked hard to achieve your goal of becoming a BOX2-3 DayoftheExamination Breathe: Inhale deeply, hold your breath to a count of 4, exhale s lo wly Believe: Have positive thoughts today and keep those thoughts focused on your achievements Control: You are in command Believe: This is your day Visualize: “RN” with your name registered nurse. If you believe in yourself and your goals, no one person or obstacle can move you off the pathway that leads to success! Congratulations, and I wish you the very best in your career as a registered nurse! This Is Not a Test 1. What are the factors needed to ensure a productive study environment? Select all that apply. 1. Secure a location that offers solitude. 2. Plan breaks during your study session. 3. Establish a realistic study schedule that includes your goals. 4. Continue with the study pattern that has worked best for you. Answers: 1, 2, 3, 4 Rationale: Alocation of solitude helps to ensure concen- tration. Taking breaks during your study session helps to clear your mind and increase your ability to concentrate and focus. Establishing a realistic study pattern will keep you in control. Do not vary your study pattern. It has been successful for you, so why change now? 2. What are key factors in your final preparation? Select all that apply. 1. Remain focused on the study plan. 2. Visualize the “RN” after your name. 3. Avoid studying on the day before the exam and relax. 4. Know where the testing center is and how long it takes to get there. Answers: 1, 2, 3, 4 Rationale: Focus on your plan of study and success will follow. Positive reinforcement: Write your name in large letters on a piece of paper with “RN” after your name and postitwhereyouwillseeitoften.Allowyourselfadayof pampering before the test. Wake up on the day of the test refreshed and ready to succeed. Ensure that you know where the testing center is; map out your route and the average time it takes to arrive. 3. What key points do the “Pathways to Success” empha- size to help ensure your success? Select all that apply. 1. A strong positive attitude 2. Believing in your ability to succeed 3. Being proud and confident in your achievements 4. Maintaining control of your mind, surrounding environment, and physical being Answers: 1, 2, 3, 4 Rationale: A strong positive attitude leads to success. Believe in who you are and the goals you have set for yourself. Be “proud and confident.” If you believe in your- self, you will achieve success. Maintain control and all of your goals are attainable. Your grade: A+ Continue to “Believe” and you will succeed. RN belongs to you! CHAPTER 2 Pathways to Success 17 18 Graduating from nursing school is a huge accomplish- ment. After earning my Bachelor of Science in Nursing (BSN), I reflected on all of the work that had led to that moment. The past 16 months had been a whirlwind. Memories of preparing for simulations and late nights studying for exams and completing detailed care plans flooded my mind. Though I was done with school, I knew there was one more test I would have to pass before I could call myself a registered nurse. The NCLEX® is a national licensing exam that is adminis- tered to every nursing school graduate. Passing this exam gives graduates a license to practice. I knew it would be the most important exam of my life and I was deter- mined to pass it. In addition to studying, a few things must be done in preparation for the NCLEX. Approximately 1 month before I graduated, I submitted the required paperwork and fees to my State Board of Nursing. It is important to do this well in advance, as it can potentially take months for your state board to process the paperwork. Your school will notify the board once your degree is con- firmed. Then it is a matter of waiting for your Authoriza- tion to Test (ATT). An ATT enables you to schedule your test date. Since I had done everything on my part to ensure that there would be no delays, I expected to receive my ATT within a few weeks after graduation. While I waited, I packed up my apartment and moved from Nevada to my home state of California. I also spent some time catching up with friends I had not seen in months. Within a few days of arriving home, I received myATT.Iwantedtotaketheexamassoonaspossible,soI expanded my search for testing centers to neighboring cit- ies. I did not mind driving a bit farther if it meant that I could take the exam sooner. I found that the earliest avail- able test date was 3 weeks later in a city about 45 minutes away. The only available time was 2:00 p.m., which I gladly accepted as it meant I could get a good night’s rest and avoid early morning traffic. I felt that I had a solid knowledge base from school, and 3 weeks would be more than enough time to review concepts and practice more questions. You will need to assess your personal knowledge level and confidence to gauge how much time you require to study. It is recommended to take the exam within a maximum of 3 months to ensure that you are not losing the knowledge you learned while in school. Now that I had a date marked in my calendar, I felt empowered to create a study plan. I chose to use 1 or 2 resources at the most in order to stay focused and mas- ter content realistically. Based on my research, I chose Saunders Comprehensive Review for the NCLEX-RN® Exam- ination. I used this text in nursing school and knew it would benefit me during my NCLEX preparation. Be thoughtful and selective when choosing study tools and find what works best for you. What works for some people may not work for others. I set a goal to practice 150 to 200 questions a day. The NCLEX can ask as few as 75 questions and as many as 265. I wanted to build up my test-taking endurance, which is why I chose to practice so many questions. When I answered questions, I would read the entire rationales regardless of whether I answered correctly or not. A wealth of information is included in each rationale. You will gain a better under- standing of not only content, but also why you selected an incorrect or correct answer. It is also important to read the Test-Taking Strategy, because this will provide you with a logical way of answering the question if you were not as confident in your mastery of the material as you would have liked. I prefer to study alone, and I spent most days practicing questions at home or in a nearby cafe. I made sure to take a break every hour to stretch and refresh my mind. Knowing that I had only a few weeks to study made me use my time more wisely. I knew it was only a matter of time before I would be done with the NCLEX, and I wanted to feel as if I had done everything I could to pass the exam. If there is anything you can do to alleviate test anxi- ety, do it! Two days before the exam, I drove to the test- ing center. I left my house around the same time I planned to leave on the actual test day, so I could see CHAPTER 3 The NCLEX-RN® Examination from a Graduate’s Perspective Jaskaranjeet “Jessica” Bhullar, BSN, RN what traffic would be like and the parking availability. I found a market nearby where I planned to have lunch beforetakingtheexam.Simplydoingthisdryrun helped to calm my nerves. I could visualize what my test day would look like. The day before the NCLEX, I chose to relax my mind, so I didn’t practice any questions. I made sure to put my ATT and identification (ID) aside because they are required at check-in and I didn’t want to forget them. I spent the day with my family and went to bed early. Keep in mind that the exam can take as long as 6 hours, so adequate sleep is a must! OnthedayoftheNCLEX,Ileftmyhouseafewhours early so I would have a chance to eat lunch and practice a few questions, just to get into test-taking mode. I believe that a positive mental attitude is important in life and especially in potentially stressful situations. I knew that in a matter of hours, the exam would be over. It does not matter at what question number your computer turns off, but rather that you answered each question thought- fully and to the best of your ability. I arrived at the testing center 30 minutes early. I was aware that lockers are pro- vided, but I brought as little as possible with me. The check-in process involves showing your ATT and ID, having your fingers and palms scanned, and having your photo taken. You will also be given a form with instruc- tions about the exam, which you will be required to sign. It is all very straightforward. I was directed to a computer in the testing room. I took a deep breath and began the exam. I treated each question as if it was the last one I had to answer. Before I knew it, I was on question number 75 and I clicked submit. The computer shut down and I felt a wave of relief. I was done with the N C LEX! I left the testing center feeling confident. The ques- tions had become difficult very quickly, and I took that as an indication that I was doing well. I replayed the questions in my mind on the drive home, and began to dwell on a couple I had been unsure about. I didn’t allow myself to become consumed by self-doubt because the exam was over and there was nothing I could do but wait! Acouple of days later, I found out I was officially a registered nurse! My lifelong dream was now a reality. I had worked so hard for this, and felt that now I could celebrate with my friends and family. The NCLEX is the last hurdle you will have to jump over before you begin your professional career. It may be tempting to put off taking the test until you feel 100% prepared, but the longer you wait the more likely it is that you will forget content you learned during school. Believe in yourself and your education! Use your time wisely and reduce anxiety however you can. I hope these suggestions will benefit you. Congratulations for all you have and will accomplish, and the best of luck in your new career!