NCLEX-RN Study Advice

ravenpuff, BSN, RN

Scroll down to WHAT I LEARNED to get what you came here for.

Disclaimers:

Everyone studies differently, and what works for me will not work for everyone.

None of the tips are absolute guarantees: there will always be a question that seems to contradict what you'll read here.

Fluff about Ravenpuff:

I graduated from a BSN program in early May 2016 and took my exam in late June 2016. I was a B student who felt more capable at my clinical site than I did in the classroom. I also worked as a CNA during nursing school (not essential but highly recommended).

How I studied for the NCLEX:

Weeks 1-2: Focused Review

I used a hard copy of Lippincott Q&A NCLEX-RN to help me determine which organ-systems I was struggling with. I aimed to get 60% correct for each chapter exam that I took (though did not complete every single chapter). Turns out I was great with pulm, cardiac, and renal, but I was not good at GI and heme/onc, so I did extra practice questions on GI and heme/onc using a couple of Davis NCLEX-RN ebooks that were available via my university library.

Weeks 3-4: Comprehensive Review

Once I was able to hit around ~60% correct for my organ-system practice exams in Lippincott and Davis, I moved on to comprehensive reviews with the Holy Grail of NCLEX reviews, aka UWorld. Uworld is a bank of about 1800 questions, and the program lets you take exams of 75 questions max at a time. I aimed to complete about 2-3 UWorld tests per day (each test with the max of 75 questions) leading up my NCLEX. By the time I took my NCLEX, I was averaging about 65% on Uworld exams. UWorld will make you confident in your ability to tackle the SATAs and prioritization questions, and will virtually eliminate the need for you to consult your nursing textbooks because its rationales are logical and detailed. I did dabble with a Kaplan review book that I borrowed from my local library, but at the risk of sounding like a Uworld snob, I thought that Kaplan's rationales were very disappointing and the questions were not challenging enough.

Day of the Exam

After checking in and sitting down at the computer, I put on the noise-cancelling headphones and took several deep breaths. I had one math problem, several prioritization questions, and a handful of SATA, and a good number of questions that tested my knowledge of PPE/isolation precautions. After 75 questions, it stopped my exam. It was a very hard test, and I was crushed by the end, thoroughly convinced that I might as well have wiped my tears and snot on the computer screen instead of taking the exam as seriously as I did.

After walking out of the testing site, I went to the public restroom and cried some more, then went home and listened to some punk rock as loud as I could possibly tolerate.

I made plans to make a new study schedule and cancel a whole bunch of events I had already planned to attend for the summer,

But....I checked my BoN site a day later and saw "Examination Status: passed"

And you can do it too! Allnurses.com was an essential resource for positive encouragement and study tips, so I'll pay it forward by sharing with you my NCLEX strategies.

WHAT I LEARNED

When prioritizing order of patients to be seen, ask yourself...

✔️ Who has a condition that involves a threat to their Airway, Breathing, Circulation, or consciousness (we'll call it ABC+C)? Put this/these patients at the top of the list

of your ABC+C patients, which of them are in imminent (aka immediate) danger? (at risk for harm vs facing actual harm?)
neuro changes from expected baseline are usually a priority finding, especially if it was a neuro change plus vomiting because of the association with increased ICP
life > limb (in other words, saving a pt's life takes priority over saving another pt's leg or arm)

✔️ Does the patient potentially have an issue based on the data given, or does the data provide evidence for a problem that is present at this moment?

remember that a threatened air way takes priority over a loss of blood. What does it matter if you stabilize your patient's fluids if they can't breathe?

✔️ But wait, all my patients seem to be stable! If that is case, then ask yourself...

Which patient is at risk for, or already has an active infection?

But remember, ABC+C is priority over active infection; for example, you'll die quicker from a ruptured abdominal aortic aneurysm than you would from peritonitis
usually the least unstable patients are the ones who is exhibiting s/sx that are

not imminently life-threatening
expected to be seen in their given diagnosis/condition

For example, compare the post-op pt with hypoactive bowel sounds (expected in post-operative patients) vs the traction patient whose pin sites are oozing purulent drainage (not expected for traction patients!)

Once you have narrowed your answer to your two most critical patients, ask yourself...

"Who will die the soonest and/or suffer the most harm if I don't tend to them now?"

and this will usually guide you toward the correct answer. Again, check your ABC+C and risk of harm vs. actual harm.

✔️ Toxic megacolon is probably the only instance in which a bowel obstructed patient could take priority over your other patients (unless of course another patient is at risk for threatened ABC+C) because of its association with bowel perforation and subsequent risk for infection of all the other internal organs

furthermore, toxic megacolon is an awesome band name, or an awful band name, depending on who you ask

If the prioritization question asks you to prioritize pts based on their lab values...

✔️ First determine which labs are abnormal. If only one is abnormal, that one is your answer.

✔️ But if more than one lab value is abnormal, determine which one will most likely lead to imminent death or harm, considering what you know about the patient in the question? The most threatening lab value is usually the right answer.

use ABC+C to guide you here; usually, an abnormal BUN/Cr is less threatening than a set of abnormal ABGs.
You can usually eliminate the choice(s) containing an abnormal lab that

is expected for the pt's given situation (eg. low Hgb in a sickle cell pt or high BNP in a CHF pt)
does not imminently threaten ABC+C and consciousness

For example: let's say you have two liver failure patients and both have abnormal labs.

Pt A has low albumin Pt B has high ammonia.

Both of these findings are abnormal, but which lab is most threatening to the pt's ABC+C?

Recall that high ammonia levels are associated with hepatic encephalopathy, which threatens the patient's neuro system, which therefore threatens their consciousness.

So, I would attend to Pt B first.

When in doubt Hypo- or hyperkalemia almost always takes precedence over all other abnormal labs due to risk of fatal cardiac arrhythmias.

Petechiae and purpura are usually a critical findings because of their association with thrombocytopenia and therefore indicate that the patient is at risk for bleeding

Mild temps are expected in the immediate post-op period.

Hypokalemia increases risk for digoxin toxicity

Live vaccines should not be given to the pregnant or the immunosuppressed. These vaccines include the NASAL version of the flu vaccines, the MMR vaccines, and varicella vaccine

Keep suction equipment at the bedside for any patient who has a condition that threatens to obstruct their airway (trach pts, TEF and/or EA, surgeries around the throat area, etc. )

When you are doing patient education about drugs:

✔️ Remember there are expected side effects and then there are life-threatening side effects that will harm a patient's ABC+C. Therefore, the priority education topics will almost always be related to ABC+C

This strategy sometimes comes in handy when the question asks you to educate the patient on a drug whose name you don't recognise.

✔️ Know which drugs are nephrotoxic because the answer usually involves telling the pt should to drink lots of water with that medication

✔️ If the question is about lithium, remember that you want to prevent the pt from becoming hyponatremic, as this will increase risk for lithium toxicity.

lithium has a narrow therapeutic range; keep it at (0.6-1.12 mmol/L) and definitely keep below 1.5

✔️ If the question asks you to choose the most important point to emphasize when teaching about a medication, choose the option that is most unique to that drug (eg. almost all drugs are to be stored in a dark cool place, but if you know that the drug in the given question causes orthostatic hypotension, choose the answer relates to this side effect)

✔️ Antacids can decrease the effect of pretty much every medication, so don't take meds with antacids.

pregnant women should avoid antacids with aluminum or sodium

✔️ When given a list of meds and the question asks to you choose which med order(s) to clarify with the prescriber, ask yourself...

which med has side effects that will worsen the s/sx of the pt's current condition?
Hepatically metabolized meds prescribed for liver patients, or nephrotoxic drugs in renally compromised patients are usually the ones to be questioned
also have a general idea of what meds are NOT for pregnant ladies (metformin comes to mind here)
make sure the prescription has five rights

The questions presents some data, then asks what to do next for that patient. How do you decide the next course of action?

✔️ Ask yourself which choice most appropriately addressed the problem that the assessment data was describing (if the issue is an airway problem, which of the choices will maintain a patent airway?)

✔️ Ask yourself if further assessment was needed.

Sometimes you do assess further, especially if the question about a patient concern then presents some data that contains everything you need except for an important detail. For example, let's say that the question gives you a CHF pt who needs her digoxin. The question gives you the pt's metabolic panel (all normal) and vital signs (all normal) but oddly enough, potassium is missing from the metabolic panel. Since hypokalemia increases risk for digoxin toxicity, the next course of action would be for the RN to further assess the pt's potassium level before giving the digoxin.

however, do not delay interventions if you have all the data you need, especially if the patient's ABC+C is threatened
if you are deciding between further assessment vs taking action, ask yourself if any additional data will significantly alter your intervention, or will it just tell you what you already know?

RNs CANNOT OBTAIN CONSENT. For some reason, I was always tripped up by this, so learn from my mistake. It is the doctor who obtains consent, not the RN. The RN's role is to verify that the patient gave consent, document that consent was given, and clarify questions about the surgery (clarification is not the same as education about the surgery; the surgeon is the one who educates the patient)

When tackling the ever popular SATA questions, be aware of the distracting choices that aren't necessarily bad nursing practice, but they don't address the stem of the question you're reading.

For example, let's say the questions asks you to SATA all the things the RN does to prevent infection when accessing a CVC. One of the options is "waste the first 10mL of the blood draw." It's not bad practice to waste the first 10mL of blood when doing labs (I think it's actually part of most facilities' protocols), but this action does not address infection prevention. A better answer is to "scrub the port for 30 seconds before accessing it."

Should you call the Doctor?

✔️ Check the other options to see if the Doctor would ask you to complete them before calling him.

for example, if you have a hypoxic patient, apply prescribed O2 first and check the patient's response. That way you have assessment details to give the Doctor before you call.

✔️ If you are unsure about the other options, ask yourself "will doing any of these other interventions tell me something I don't already know?"

Application of heat/hot packs causes vasodilation, so REFRAIN FROM applying heat to anything that you don't want to vasodilate, such as the appendix (vasodilation could rupture it) or a leg suspected of containing a blood clot (vasodilation will dislodge the clot).

Alcohol should be avoided entirely eg. "Pt needs further teaching when he says: "I can still enjoy drinking a glass of wine on Sundays."

People with gout should avoid what I like to call "cocktail party foods" which includes wine, cheese, alcohol, and cured meats (I hope I never get gout)

Know thy Airborne vs Droplet Isolation Precautions

I was having a hard time remembering which diseases were droplet vs airborne. So because I am lazy, I memorized just the airborne precautions because there are less diseases to remember. That way, if I encountered an isolation precautions question about a disease that wasn't one these four, I could assume that one in question was probably droplet.

Airborne
Measles
Chickenpox
Herpes zoster
TB

The anatomy of pain

Flank pain = kidney stones

Peri-umbilical radiating to RLQ = appendicitis (and keep in mind that if the inflamed appendix bursts, the patient becomes at risk for peritonitis)

RUQ pain radiating to the back = pancreatitis (radiates to back because the pancreas is a retroperitoneal organ)

RUQ radiating to shoulder = cholecystitis

If a pt is described as having some back pain AND the stem mentions that the pt has kind of cardiovascular condition or is returning from a cardiac diagnostic procedure, you should consider that the pt is probably are bleeding out from a ruptured aortic aneurysm

Excess Magnesium and Excess Calcium will cause decreased muscle tone. Think of them as depressants. They depress sodium's ability to permeate cell membrane, which lowers cellular excitability.

Almost any question involving the IV or PO contrast can be answered by addressing the need to ask pt about iodine/shellfish allergies and educating pt to drink lots of fluids in post-procedure period to flush out the contrast from the system (remember that contrast is nephrotoxic)

When sending a pt to MRI, check for metal and babies/missed periods.

Duodenal ulcer pain is relieved during a meal, but pain is returns after a meal.

DURING meal= DUODENAL relief

Strokes and their manifestations:

Right side stroke patients will be appear to be "alright" because they act without awareness of their deficits: they move around normally, but they are impulsive, show poor judgement, lack depth perception, deny their deficits, and overestimate their capabilities.

Left side stroke patients will appear "lousy" (Left and Lousy start with L) because they move slowly and cautiously, and experience depression or worthlessness from deficits

When assigning a patient to a newly graduated RN, assign only the patients that...

Require the most basic level care and basic level nursing skills, which includes

assessment of VS, lung sounds, swallowing ability, and gag reflex
maintain NPO status
prepare a basic pre procedure checklist
check for ABCs after procedure

Basically, which patient is the least physiologically and psychologically complicated?

In NCLEX-World (eye roll), the newly graduated RN should NOT care for:

new diagnosis of anything
new onset of anything
any patient with a newly prescribed IV drip involving multiple lab checks, weight-dose-calculation, or titrations according to current lab values; drugs like a heparin or insulin gtt (by "newly prescribed" I mean that the patient was not on the drip in the past)
any pts requiring extensive pre-op and/or discharge teaching that require advanced therapeutic communication (transplant patients comes to mind here)
patients with an acute onset of a condition requiring an advanced synthesis of various assessment information (I realize that this statement pretty much describes every patient you'll ever encounter in real life, but remember, this is the NCLEX-World)

TPN should be administered forever alone, meaning don't hang another med or fluid with TPN ever.

if the TPN bag runs dry and there isn't a replacement in your med room yet, hang a bag dextrose in its place to prevent pt from becoming hypoglycemic

Most drugs should be taken with meals, but some exceptions (meaning, pt should take these meds on an EMPTY stomach) that I can remember are

Iron supplements (encourage pt to take with juice or foods high in vitamin C. Avoid taking iron with milk)
Levothyroxine
zolpidem/Ambien
bisacodyl/Dulcolax

As other testers have recommended, do not delegate to LPNs and UAPs/CNAs what you as the RN can E.A.T. (educate, teach, or assess).

At the risk of offending the CNAs out there, it helped me to think that in
NCLEX -World, the UAPs as basic-level mindless robots: mindless robots can measure I&O, take vitals, weigh pts, turn pts, feed pts, empty drains, obtain blood sugars, and ambulate with stable patients but that is pretty much it.
However, UAPs should not measure vital signs in the first 15 minutes of blood transfusion, nor should they ambulate with the fresh post-op patient

*Again, these tips in the context of NCLEX-World only. Please understand that I do not think of real life CNAs as robots at all. I was/am a CNA. We are way more capable than mindless robots.

Decorticate posturing vs decerebrate posturing

Decorticate posturing is characterised by flexion posturing, while decerebrate is mostly extension posturing. Also, "extension" and "decerebrate" are spelled spelled with lots of letter E's.
A transition from decorticate to decerebrate posturing is a worsening sign.

Important items to study for Mother-Baby content included

✔️ pre eclampsia and eclampsia care, include assessment findings, Mag sulfate administration (know therapeutic mag levels, signs of mag toxicity)

✔️ If you see variables decelerations followed by accelerations AND this all occurred AFTER the mother reports a gush of fluid, RN should suspect cord compression

✔️ Types of placental problems

placenta previa covers the uterus and is characterised by painless spotting?
placenta accreta is a deeply attached placenta (accreta sounds like 'a creeper', which is a person who is too deeply emotionally attached to you... I know it's weird. but this mnemonic makes sense to me)
abruptio placentae (which sounds like a Harry Potter spell) is when the placenta abruptly starts to peel away from the uterus (are you cringing? me too) and presents with uterine tenderness
is often associated with mothers who used cocaine during pregnancy because of its vasoconstrictive effects.

✔️ When you look at fetal heart rhythms, decreased variability and late decelerations are BAD and correct answers usually involved...

turning mom on side or in knees-chest position
giving supplemental O2 and/or a fluid bolus (bolus boosts amniotic fluid volume to prevent further cord compression)
stopping the oxytocin drip if the fetus shows any sign of fetal distress

If you take away nothing else from Mother/Baby...

FHR is 120-160 bpm
neonatal RR is 30-50
baby's heelstick glucose should be between 40-70
infants belong in a rear facing car seat in the back seat

You won't be able to remember every detail for every drug, but I definitely invested effort in learning about

insulin (especially onset, peak, duration times for each type)
corticosteroids (especially its adverse effects)
diuretics (remember "spare"-onolactone [aka spironolactone ]spares potassium)
digoxin safety measures (count pulse, monitor serum potassium)

Orange -colored urine is not an alarming finding in patients on antibiotics

A high-pitched cry in an infant is almost always a priority finding.

Someone on a nursing student forum once referred to lactulose as "***-Lasix for ammonia" After reading that, I never forgot the therapeutic action of lactulose again.

Within your exam, NCLEX gives you fifteen 'experimental' questions that do NOT count against your score, but rather are used by test developers to ensure that the NCLEX is a fair exam. You will not know which of your questions are the 'experimental' ones.

NCLEX is all about safety. When in doubt, choose answer that will make the patient safe.

Be forgiving to yourself when you get questions wrong on your practice exams. This is a learning moment! Wouldn't you rather get a question wrong on a practice test than the actual NCLEX?

If this guide has helped even just one or two people score better on their exams, I will be happier than a post-op patient with a cup of ice chips

Feel free to PM me with feedback or corrections.

NCLEX-RN Study Advice

Fluff about Ravenpuff: