Help with NCLEX-RN – Let’s do some sample questions

SafetyNurse1968, ADN, BSN, MSN, PhD

WHAT DOES THE RESEARCH SAY?

Google “How to pass the NCLEX-RN the first time” and you’ll get many results, some of them more reliable than others. You’ve learned in nursing school that it’s important to look for evidence-based resources, so I thought I’d back up my NCLEX success tips with hard facts. Evidence for educational strategies that support NCLEX success is rare, but there are some studies out there with interventions that correlate with NCLEX success.

Success on the NCLEX-RN actually starts before admission to nursing school. Studies have shown that pre-admission scores on reading and math assessments, pre-clinical GPA and scores on the NLN-PAX-RN are all predictors of NCLEX success.^{1, 2}

Several studies stressed the importance of setting up a test preparation plan and sticking to it. A few hours each day of nonnegotiable study time is crucial. Put it on your calendar.^{2, 3}

A qualitative study asked nursing students what they thought contributed to their first-time success on the NCLEX-RN. She interviewed 12 students and grouped their responses into four categories: 1) practicing NCLEX-RN questions; 2) nurse clinical experiences; 3) receiving support; 4) participating in an NCLEX-RN review course.⁴

Another study was an evidence-based education project with BSN students. They provided students with coaching, test-taking strategies, study groups, review courses, review books, self-assessment, as well as time management, relaxation and anxiety reduction techniques.³

There are many comprehensive exams that mimic the NCLEX (Often called RN-CAT): Mosby, NLN, HESI, ATI all assess preparedness. There is a correlation between scores on standardized exam like HESI or ATI and passing the NCLEX. ¹

NCLEX-RN FORMAT

Multiple studies mentioned the importance of understanding the test format, so let’s review^{1, 4}:

You will have between 75-265, and that includes non-scored experimental items. You will also have 6 hours. As I am sure you know by now, the test is adaptive and the length of the exam and the specific test items depend on the candidate’s knowledge level and ability. If you get one right, a more difficult item is next. If you get one incorrect, an easier item is next.

The test is scored with something called a logit, a unit of measure used to calibrate items. It is a prediction of the probability of an event. The higher a person’s ability relative to the difficulty of an item, the higher the probability of a correct response. This means the computer can make a pass/fail decision with 95% confidence. The idea is to determine at what point the candidate is answering items correctly about half the time.

After item 75, the computer calculates the standard error to estimate candidate competence. If it’s at or above competency, the computer shuts off. If it’s below, the computer shuts off. It only keeps going if more items are needed for a statistically significant measurement. Two things can happen to cause the computer to use the last 60 items to estimate your score: you reach 265 questions, or time runs out.²

HOW TO FAIL

Students who failed the NCLEX-RN the first time, identified inadequate study habits, lack of knowledge about how to prepare for the exam, difficulty setting priorities and poor test-taking skills. Students felt most prepared for patient priorities and delegation and least prepared for maternity/newborn, pediatrics and pharmacology.¹

There are some factors beyond your control. If you are a student who is experiencing English as a second language, if you have educational deficits, a low preclinical GPA or test anxiety, studies show you are more likely to fail the NCLEX-RN.^1,2

In addition, there is a strong relationship between a delay of more than 3 months post-graduation before taking the NCLEX-RN and failing.¹

PRACTICE, PRACTICE, PRACTICE

I know you’ve heard this so many times from your professors and your friends, but it’s true. The more questions you do, they better you’ll do on the exam. It’s important to understand question structure and use practice questions to prepare. Practice questions force you to analyze the stem and understand what the question is asking. You’ll improve if your practice questions have the rationale for content and for incorrect answers.

SAMPLE QUESTIONS

ONE

A client had an IV started at 0900. At 0930 the client rings to complain of shortness of breath. The client has a blood pressure of 90/60 mm Hg from a baseline of 130/82 mmHg, and a pulse of 110 beats per minute. Which of the following should the nurse do FIRST?

Check the IV tubing for air bubbles
Assess the IV tubing for loose connections
Clamp the tubing and turn the client on the left side
Raise the head of the bed

Rationale: This client is showing signs of air embolism, which is a complication of Intravenous therapy. When a client complains of shortness of breath, there is a need for immediate intervention, and no further assessment is required. The correct interventions for air embolism include: clamping the tubing, turning the client on the left side with the head of the bed lowered to Trendelenburg to trap the air in the right atrium, assessing vital signs and breath sounds, administering oxygen and notifying the HCP. Complications of air embolism include shock and death.

Options 1 & 2) Checking for air bubbles and loose connections are correct prevention activities, but do not address the presence of a presumptive air bubble already in the client’s bloodstream.

Option 4) Raising the head of the bed may cause the air embolism to migrate to the lungs or brain.

The correct answer is option 3

Competency: Pharmacological and Parenteral Therapies, IV Therapy

Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Philadelphia, PA: Wolters Kluwer. Pg. 291

Taylor, C., Lillis, C., Lynn, P. & LeMone, P. (2015). Fundamentals of Nursing (8th ed.). Philadelphia, PA: Wolters Kluwer. Pg. 1510

TWO

A nurse on an oncology unit receives verbal report about four patients. Which client will the nurse see FIRST?

A client with a total serum calcium level of 10.8 mg/dL, complaining of fatigue and nausea.
A client with a temperature of 100.1 oF and a neutrophil count of 950 neutrophils/mcL
A client with lymphoma who has shortness of breath, edema of the neck and arms and difficulty swallowing.
A client with metastatic breast cancer, complaining of throbbing and aching joint pain and a platelet count of 50,000/mm3.

Rationale: 1 & 3 are oncologic emergencies, however, option one indicates hypercalcemia, which is potentially life-threatening metabolic abnormality resulting from calcium release from the bones exceeding the ability of the kidneys to excrete calcium. Symptoms include serum calcium above 10.1, fatigue, weakness, confusion, polyuria, nausea and vomiting. Answer option three is a true oncologic emergency that can progress to cerebral anoxia, bronchial obstruction and death. Signs and symptoms of Superior Vena Cava Syndrome (SVCS) include dyspnea, edema of neck, arms, hands, skin tightness, difficulty swallowing, distended jugular veins and increased ICP. SVCS is associated with a diagnosis of lung cancer and lymphoma. It Option two indicates a client who may be developing neutropenic fever, which is associated with any temperature of 100.4oF and a neutrophil count of <1000 neutrophils/mcL. This client has the potential for developing an emergency but is not a priority. Option four indicates probable pain from bone metastasis. It is important to treat pain, but it would not be the priority. The platelet count is low, but not low enough to be associated with spontaneous bleeding (<20,000/mm3).

The correct answer is option 3

Competency: Management of Care, Establishing Priorities, Oncology, Evaluation

Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Philadelphia, PA: Wolters Kluwer. Pgs 372, 377, 382

Taylor, C., Lillis, C., Lynn, P. & LeMone, P. (2015). Fundamentals of Nursing (8th ed.). Philadelphia, PA: Wolters Kluwer. Pg. 1482

THREE

The nurse is assessing a client for the possibility of pregnancy. Which of the following statements by the client indicate probable signs of pregnancy? Select all that apply.

“I’ve been nauseated every morning and I haven’t had a period in two months.”
“I’m just so tired all the time.”
“I took a pregnancy test and it came up positive.”
“My breasts are much larger, and my nipples are sore.”
“I’ve been having irregular contractions.”
“My boyfriend felt the baby moving.”

Rationale: Options 3 & 5) are probable signs of pregnancy. Although probable signs suggest pregnancy and are more reliable than presumptive signs, they are still not 100% reliable in confirming pregnancy.

Options 1, 2 & 4) are presumptive signs of pregnancy. These are the least reliable indicators of pregnancy because any one of them can be caused by conditions other than pregnancy. Amenorrhea can be caused by early menopause, endocrine dysfunction, malnutrition, anemia, diabetes mellitus, long-distance running, cancer or stress. Nausea can be caused by gastrointestinal disorders. Fatigue can be caused by anemia, stress or viral infections. Breast tenderness can be caused by chronic cystic mastitis, premenstrual changes or use of oral contraceptives.

Option 6) Palpating for fetal movements is a positive sign of pregnancy when performed by an experienced healthcare provider. Fetal movements that have not been confirmed by an experienced practitioner are considered presumptive signs.

The correct answer: options 3 & 5

Competency: Health Promotion and Maintenance, Health screening, Antepartum, Assessment

Ricci, S. S., Kyle, T. K., & Carman, S. (2017). Maternity and Pediatric Nursing (3rded.). Philadelphia, PA: Wolters Kluwer. 363-364

Taylor, C., Lillis, C., Lynn, P. & LeMone, P. (2015). Fundamentals of Nursing (8th ed.). Philadelphia, PA: Wolters Kluwer. Pg. 1665

FOUR

The nurse has been teaching a client about a new prescription for carbamazepine (Tegretol) for tonic-clonic seizures. Which of the following statements by the client indicates need for further teaching?

“I should call the doctor if I notice a rash or blurry vision.”
“If I experience nausea or blurry vision, I should stop taking the medication immediately.”
“I need to take the medication with food, but not with grapefruit juice.”
“I need to take the medication twice daily at the same time each day.”

Rationale: Option 1) Toxic effects of carbamazepine include severe skin rash, blood dyscrasias and hepatitis. Visual disturbances and serious skin reactions should be reported.

Option 2) Client education about carbamazepine includes teaching that medications should not be discontinued, even if adverse side effects occur such as rash, dizziness, nausea or blurry vision; however the healthcare provider should be called if there are adverse side effects.

Option 3: Giving medication with meals can reduce the risk of GI distress, however grapefruit juice may increase absorption.

Option 4): Strict maintenance of drug therapy is essential for seizure control.

The correct answer is option 2

Competency: Pharmacological and Parenteral Therapies, Adverse Effects/Contraindications/Side Effects/Interactions, Evaluation

Hodgson, B. B. & Kizior, R. J. (2014). Nursing Drug Handbook. St. Louis, MO: Elsevier. Pgs 180-182

Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14thed.). Philadelphia, PA: Wolters Kluwer. Pg. 2000

FINAL ADVICE

Take advantage of end of program review options. The NCSBN offers an online review course of 3, 6 or 9 weeks – the candidate has 24/7 access to material. Since the NCSBN is the organization that “writes” the NCLEX, I think this would be the one to take if you had to pick just one.⁵The most important thing you can do to increase your chances of passing the NCLEX-RN is to accept responsibility for your success.

For more tips and tricks, check out another article I wrote – it will lead you through strategies for understanding the stem and choosing the correct answer option: Are You Ready for NCLEX? Think PATIENT SAFETY and You Will Be!