OK, So where did I learn this...?!

steven007, BSN, MSN

We've all been there, sitting in the exam room (be it for your RN license exam or just a nursing class exam) and you're confronted with that question that makes you ask yourself "OK, so where did I learn this?".

They seem to happen more often than none, at least for me they do. And if you're anything like me, when you are continually confronted with these questions you begin to, not only get really irritated, but start to question whether or not you actually know your material! You study, study and study some more but no matter how much you cram, which books you read, you are continually presented with questions that just stump you!

As a nursing student, I have identified 4 types of nursing questions in a nursing exam and I also come up with tips on how to answer them. These are just my own personal opinions on them and this is my own personal classification of questions, but I hope it helps other people like me in the long run.

So anyway, let's get down to business shall we? The four types of nursing questions I have identified are the impractical anarchists, the impossibly experienced, the evident, and the not-so-evident (otherwise known as the crossover).

The impractical anarchists: The impractical anarchist questions are those questions that are extremely inappropriate for new nurses and nursing students. They are the ones that ask you questions where the answer generally violates a rule (but not always!). A good way to find these questions is by looking for one of the answers being "notify the physician". When you see "notify the physician" is a potential answer, there is a good chance you have an impractical anarchist question. Personally, I feel the answer they expect for these types of questions are shaped, not only by nursing experience, but also by comfort in the nursing progression and knowledge of how it works.

Let's give you an example

You are presented with a generically named patient who suffers from COPD. Upon assessment, the nurse finds the patient to have blue nail beds, clubbed nails and an SP02 of 82%. The nurse notes the patient is in respiratory distress.

What should be the nurse's first action?

a) Administer O2 at 2L a minute
b) Notify the physician
c) Position in high fowlers
d) Perform a respiratory assessment

Well, first of all, ALL of these possible answers are correct; but the "most correct one" is a, administer O2 at 2L a minute. EVEN THOUGH administering O2 requires a physician's order.

The issue I have with this is, sure, an experienced nurse should and has every right to administer oxygen in this situation. But a new nurse may not be so quick to risk her license and job. I know I wouldn't. I mean, I know that this is the answer they expect, but I know personally I would be hesitant to do such an act as a new nurse!

But the fact is these questions are probably here to stay for a while, so here are some tips for answering these questions, unfortunately these questions require a bit of critical thinking. If you see notify the physician as a potential answer chances are 90% you have an impractical anarchist (IA) question, so your next step is review the question in great detail, paying attention to the theoretical client's status. Pay careful attention to every detail about the client's current medical status. After doing this, without looking at the possible answers, ask yourself "if I was in a huge hospital that only had one doctor who wasn't available for an hour, no matter the situation, what would I do to keep this patient alive?" Answer that question and if your answer is a potential answer for the question, it's likely to be the correct one. Let's breakdown the previous example, as it is a common question to encounter in your nursing exams (review the question above).

So, you read the question and see notify the physician as an answer. So now you are going to reread it, paying EXTRA close attention to the very little details of the question, specifically the details pertaining to the patient's medical status. So in this question that would be: COPD patient, cyanosis, clubbed nail beds, SpO2 of 82% and VERY importantly the patient is in respiratory distress. So then ask yourself, with these details what would be the smartest thing to do, to preserve this patient's life and optimize comfort? Probably give oxygen, right? If you're not sure, then read through each of the possible answers, and this is only if you're not sure OR your proposed solution was not a potential answer.

Let's review the possible options

a) Giving O2 would defiantly help increase his oxygen saturation. And seeing that the patient is in respiratory distress, the nurse can almost guarantee that the doctor will prescribe O2.
b) You definitely would notify the physician; however, in the time it would take to leave the patient and notify the physician, just to wait for him to return and assess the patient, the patient's oxygen status is going to drop significantly and his condition is going to deteriorate, potentially to a point of no return.
c) Positioning the client definitely will help, but positioning the client as a single nursing intervention will not yield sufficient results for a client in respiratory distress.
d) You definitely would do this, but would this be the FIRST thing you do, when you have a patient in respiratory distress? Assessing the respiratory system is not going to change the fact that.. he is in respiratory distress. You can also clearly see the patient in respiratory distress as an objective observation, which is technically part of your assessment already.

Now this is an ideal question, but let's say that none of the possible solutions would preserve life.

Let's say, for example, these were the possible answers for this particular question

a) Notify physician

b) Administer nitro

c) Perform respiratory assessment

d) Administer Lasix as prescribed

So, aside from notify the physician, none of these possible options would preserve life for any extended amount of time. So in this particular situation, the correct answer would be "notify the physician". However, in all my years of nursing tests, whenever notify the physician was a potential answer, it NEVER was correct. I have, only once, seen the correct answer as "notify the physician". But this is my personal anecdote. Just be careful and try to approach it as I have explained, I'm sure it will help you!

The impossibly experienced: These questions SUCK, royally. I absolutely hate these types of questions because they require thinking within thinking. These questions offer no alternative other than being impossibly experienced, or having read every nursing textbook in existence.

Here, let me come up with an example for you

Janice's total parenteral nutrition (TPN) solution is postponed one day because she is off the unit for an ultrasound. She is behind a total of 500 mL of solution. The solution is running at 200 mL per hour.

What should the nurse do in this situation?

a) Do not make up the 500 mL
b) Increase the ordered flow to 220 mL until the 500 mL is made up
c) Take the solution off the infusion pump and increase the rate to 300 mL per hour
d) Offer Mr. Ford increased fluids by mouth

Here are my tips for these types of questions (I'm not going to tell you the answer yet, I'm going to go through the possible options first and tips, just to see if you figure it out. And if you already know what the answer is well, good for you).

First, identifying these types of questions. Identifying an impractical professional question is somewhat hard and depends on the student's ability as a nurse. Impractical professional questions are almost ALWAYS clinical questions, they are never theoretical! They usually always ask "what would you do?" or "what would the nurse do in this situation?" Another way to identify them is when you read the answers and you just feel stumped, they all seem wrong or flawed. An impractical professional question never has all the right answers, or you will never feel that they are all right. At least, personally speaking. When all the questions seem correct and you are sure they seem correct, you don't have an impractical professional question.

Now let's go over how to answer these types of questions. I personally think these are the hardest questions to answer, but if you work in stages, then you should fair better at coming up with a correct answer. First, reread the question as always, paying attention to the issue at hand. In this case, it's the fact that Mr. Ford is behind 500 mL of solution. Then ask yourself, why is this a problem? In this case, being behind 500 mL can lead to fluid and electrolyte imbalances, dehydration and a whole slew of other wonderful complications. Then, use common sense pertaining to the issue and the problem. So you would use common sense, thinking about Mr. Ford missing his 500 mL of fluids and being at risk for fluid & electrolyte problems, thus omitting any obvious bad ideas.

Let's take a look

a) This is OBVIOUSLY severely incorrect! You are NOT going to just ignore the fact that he is missing his fluids. By doing this you are putting him into fluid imbalance!
c) Taking the solution of an infusion pump just seems like a really bad idea. Especially when you are dealing with solutions that can cause severe reactions if not handled properly (hypertonic solutions can do a lot of harm if not regulated appropriately).

So, we just ruled out a and c, simply using common sense! Now we are stuck with the two final, potential candidates which we can further use common sense on! You may ask, why don't we just use common sense right off the bat? Well, the answer to that is, it is easier to decide between two possible options, than between 4 possible options. So it is VERY important that you ALWAYS narrow your potential options down to the lowest amount possible!

b) Increasing to 220 may not be the best thing to do but it is more likely than d) in which we are offering him fluids by mouth.
d) Fluids by mouth are almost always contraindicated for this type of patient (receiving TPN). So that makes the most probable answer b.

So, yeah, b is the answer. You can do it that way or you can just remember that a nurse can increase the infusion rate of TPN but 10%. But I didn't know this when I read the question. And it is impossible for a student to know EVERYTHING about nursing, that's why multiple-choice tips are very useful!

The Evident: Then there are the questions that everyone loves and are grateful for, the evident questions! These questions are generally straightforward and easy to answer. These questions are easily identifiable. They ask questions that are very common sense. HOWEVER, it is the evident questions that are the trick questions. When you are presented with questions that are overally easy, proceed with caution! Read the question looking for KEY words, because a simple word can change the correct answer!

Here's an example

What is the most effective method for the nurse to validate the effectiveness of pain relief with most clients?

a) Ask clients to rate their pain verbally on a scale of 1-10
b) Monitor their facial expressions before and after administration of analgesics
c) Monitor their vital signs and responses to analgesics given
d) Ask clients to rate pain using a numeric rating scale before and after analgesics

Well, to rate the effectiveness in MOST clients you would simply ask before (to obtain a baseline) and after (to compare to the status of the patient pre-administration of analgesics to see if they're actually effective or not). See, common sense! But you have to be careful because technically you would rate client's pain perception by a, asking the client to rate their pain verbally on a scale of 1-10. However the question was asking the EFFECTIVENESS, meaning you need to establish a baseline to compare it to, thus making the correct answer d.

The Not-So-Evident

Then finally, there are the awful questions. The not-so-evident, or as I like to call them, the crossover questions. These questions take a little bit from all the other types of questions and combine it into one super question.

Most questions have some crossover question properties, more notably the impractical anarchical questions which generally have all correct answers. However, when you break down an anarchical question, you will see that there truly is a best answer, based on logical thinking.

There is no sure way to identify a crossover question. They usually require the application of previously learned facts, with critical thinking and application. Crossover questions are always math related questions.

Here is an example:

Billy, a 1 month old, is receiving ampicillin every six hours. The hospital formulary indicates that a safe dose is 200 to 400 mg per kg per day. What is the recommended dosage range for Billy per day, who weights 11 pounds?

a) 11,000 - 44,000 mg per day
b) 1100 - 4400 mg per day
c) 1000 - 2000 mg per day
d) 1000 - 2000 mg per dose

So, this question requires a lot more thinking than you may imagine. First, you have to know that 1 kg = 2.2 pounds. Then you must divide 11 pounds by 2.2 to get Billy's weight in kg, which equates to be 5 kg. You then must multiply 5 by 200 and 400 to get the min and max dosage. You then have to pay very careful attention to the wording. The question is asking the recommended dosage range for Billy PER DAY. So, we have to pay attention selecting the appropriate answer that coincides with the question. In this case, it's c. It cannot be d because d is giving you the max and min per dose, which is not the measurement we are given on the formulary. The formulary is giving us the min to max dosage PER DAY.

So as you can see, this question overlapped a bit with other types of questions. These questions are not generally difficult provided you pay attention to the wording and you have a solid background in nursing science. These questions simply require attention to detail and critical thinking. If you want to know how to identify them easily, they are ALWAYS the dosage related questions, especially IV questions (again, math related). Whenever you are given an IV question or a question about dosage, that is your not-so-evident, crossover question.

So that wraps up that. I hope these have proved somewhat useful for you! Try doing online practice NCLEX questions using the principles in this article and see if it helps!

Good Luck!