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Saunders Nclex Pyramid to Success
Adult Health II (NUR 2211)
Hillsborough Community College
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C H A P T E R 1
The NCLEX-RN® Examination
evolve.elsevier/Silvestri/comprehensiveRN/
The Pyramid to Success
Saunders Comprehensive Review for the NCLEX-
RN® Examination
About This Resource and the NCLEX-RN® Examination
Welcome to the Pyramid to Success and Saunders Comprehensive Review for the NCLEX- RN® Examination. This resource is specially designed to help you begin your successful journey to the peak of the pyramid, becoming a registered nurse. As you begin your journey, you will be introduced to all of the important points regarding the NCLEX-RN examination and the process of testing, and to unique and special tips regarding how to prepare yourself for this important examination. You will read what a nursing graduate who recently passed the NCLEX-RN examination has to say about the test. Important test-taking strategies are detailed. These details will guide you in selecting the correct option or assist you in making an educated guess if you are not entirely sure about the correct answer. Each unit in this book begins with the Pyramid to Success. The Pyramid to Success addresses specific points related to the NCLEX-RN examination. Client Needs as identified in the test plan framework for the examination are listed, as are learning objectives for the unit. Pyramid Terms are key words that are defined in the glossary at the end of the book and set in color throughout each chapter to direct your attention to significant points for the examination. This resource provides you with nursing content review, including the content identified in the current NCLEX test plan, and practice questions. Throughout each chapter, you will find Pyramid Point bullets that identify areas most likely to be tested on the NCLEX-RN examination. Read each chapter, and identify your strengths and areas that are in need of further review. The book contains 945 NCLEX-style questions. The Evolve site accompanying this book contains all of the questions from the book plus additional Evolve questions for a total of more than 5200 practice questions. The types of practice questions 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; audio or video item formats; and case studies (testlets). In addition, the new Next Generation NCLEX® (NGN) question types are also provided on the accompanying Evolve site. Examples of question types can be located throughout this chapter. Test your strengths and abilities by taking all practice tests provided in this book and on the accompanying Evolve site. Be sure to read all rationales and test-taking
strategies. The rationale provides you with significant information regarding the correct and incorrect options. The test-taking strategy provides you with the logical path to selecting the correct option. reference source and page number are provided so that you can easily find information you need to review in another Elsevier text. You may also review in the content review sections of this book. Each question in the book and on the accompanying Evolve site is coded on the basis of the Level of Cognitive Ability, the Client Needs category, the Integrated Process, Content Area being tested, and a Health Problem, if applicable. The Health Problem code allows you to filter and select questions based on a disease process. For example, if heart failure is the area of interest, you can select “Adult Health, Cardiovascular, Heart Failure” on the Evolve site. In addition, two Priority Concepts that relate to the content of the question are identified. This code is helpful for students specifically whose curriculum is concept-based. Additionally, information about all of the special features of this resource and the question types is located in the preface of this book.
Other Resources in the Saunders Pyramid to Success
There are several other resources in the Saunders Pyramid to Success program. These include the following: The Saunders Q&A Review for the NCLEX-RN® Examination, The HESI/Saunders Online Review for the NCLEX-RN® Examination, Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam, Saunders Q&A Review Cards for the NCLEX-RN® Exam, and Saunders RNtertainment for the NCLEX-RN® Exam. All of these resources in the Saunders Pyramid to Success are described in the preface of this book and can be obtained online by visiting elsevierhealth or by calling 800-545-2522. Let’s begin our journey through the Pyramid to Success.
Examination Process
An important step in the Pyramid to Success is to become as familiar as possible with the examination process. Candidates facing the challenge of this examination can experience significant anxiety. Knowing what the examination is all about and knowing what you will encounter during the process of testing will assist in alleviating fear and anxiety. The information contained in this chapter was obtained from the NCSBN Web site (ncsbn) and from the NCSBN 2019 test plan for the NCLEX-RN and includes some procedures related to registering for the exam, testing procedures, and the answers to the questions most commonly asked by nursing students and graduates preparing to take the NCLEX. You can obtain additional information regarding the test and its development by accessing the NCSBN Web site and clicking on the NCLEX Exam tab or by writing to the National Council of State Boards of Nursing, 111 East Wacker Drive, Suite 2900, Chicago, IL 60601. You are encouraged to access the NCSBN Web site, because this site provides you with the most up-to-date and valuable information about the NCLEX and other resources available to an NCLEX candidate. You are also encouraged to access the most up-to-date Candidate Bulletin. This document provides you with everything you need to know about registration procedures and scheduling a test date.
decisions regarding the test plan framework. The results of this recently conducted study provided the structure for the test plan implemented in April 2019.
Test Plan
The content of the NCLEX-RN examination reflects the activities identified in the practice analysis study conducted by the NCSBN. The questions are written to address Level of Cognitive Ability, Client Needs, and Integrated Processes as identified in the test plan developed by the NCSBN.
Level of Cognitive Ability
Levels of cognitive ability include knowledge, understanding, applying, analyzing, synthesizing, evaluating, and creating. The practice of nursing requires complex thought processing and critical thinking in decision making. Therefore, you will not encounter any knowledge or understanding questions on the NCLEX. Questions on this examination are written at the applying level or at higher levels of cognitive ability. Table 1-1 provides descriptions and examples of each level of cognitive ability. Box 1-1 presents an example of a question that requires you to apply data.
Table 1-
Levels of Cognitive Ability: Descriptions and Examples
Level Description and Example Knowledge Recalling information from memorizing. Example: A normal blood glucose level is 70 to 99 mg/dL (3 to 5 mmol/L). Understanding Recognizing the meaning of information. Example: A blood glucose level of 60 mg/dL (3 mmol/L) is lower than the normal reference range. Applying Carrying out an appropriate action based on information. Example: Administering 10 to 15 g of carbohydrate such as a 1⁄2 glass of fruit juice to treat mild hypoglycemia. Analyzing Examining a broad concept and breaking it down into smaller parts. Example: The broad concept is mild hypoglycemia and the smaller concepts are the signs and symptoms of mild hypoglycemia, such as hunger, irritability, weakness, headache, or blood glucose level lower than 70 mg/dL (3 mmol/L). So, for example, the question may present information that you need to interpret as mild hypoglycemia. Then, the question asks you to select the option(s) that identify the appropriate nursing action(s) to correct hypoglycemia. Synthesizing Examining smaller parts or information and determining the broad concept. Example: The smaller concepts are manifestations such as polyuria, polydipsia, polyphagia, vomiting, abdominal pain, weakness, confusion, and Kussmaul respirations. The broad concept is diabetic ketoacidosis (DKA). So, for example, the question may provide specific information about the manifestations of DKA. You need to interpret these manifestations as DKA. Then, the question asks you to select the option(s) that identify the appropriate nursing action(s), based on your interpretation that the client is experiencing DKA. Evaluating Making judgments, conclusions, or validations based on evidence. Example: Determining that treatment for mild hypoglycemia was effective if the blood glucose level returned to a normal level between 70 to 99 mg/dL (3 to 5 mmol/L) after a specified time period. Creating Generating or producing a new outcome or plan by putting parts of information together. Example: Designing a safe and individualized plan of care with the interprofessional health care team for a client with diabetes mellitus that meets the client’s physiological, psychosocial, and health maintenance needs.
Reference: Ignatavicius, Workman (2018), pp. 1331-1333.
Adapted from Understanding Bloom’s (and Anderson and Krathwohl’s) taxonomy, 2015, ProEdit, Inc. proedit/understanding-blooms-and-anderson-and- krathwohls-taxonomy/
Box 1-
Level of Cognitive Ability: Applying
The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On the basis of these findings, the nurse should implement which action?
- Remove the IV.
- Apply a warm compress.
- Check for a blood return.
- Measure the area of infiltration.
Answer: 1
This question requires that you focus on the data in the question and determine that the client is experiencing an infiltration. Next, you need to consider the harmful effects of infiltration and determine the action to implement. Because infiltration can be damaging to the surrounding tissue, the appropriate action is to remove the IV to prevent any further damage. Once the IV is removed, further action should be taken depending on the medication infusing at the time of infiltration based on agency protocol, but may include aspiration of the fluid from the site, injection of an antidote, application of warm or cool compresses for specified time intervals, and elevation of the extremity.
Client Needs
The NCSBN identifies a test plan framework based on Client Needs, which includes 4 major categories. Some of these categories are divided further into subcategories. The Client Needs categories are Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity (Table 1-2).
Table 1-
Client Needs Categories and Percentage of Questions on the
NCLEX-RN Examination
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 tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. The nurse should assemble which necessary protective items before entering the client’s room?
- Gloves and gown
- Gloves and face shield
- Gloves, gown, and face shield
- 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 oneself from contracting an infection and requires that you consider the methods of possible transmission of infection, based on the client’s condition. Note the data in the question. Because of the potential for splashes of infective material occurring during the wound irrigation or suctioning of the tracheostomy, option 3 is correct.
Health Promotion and Maintenance
The Health Promotion and Maintenance category addresses the principles related to growth and development. According to the NCSBN, this Client Needs category also addresses content required to assist the individual to prevent health problems; to recognize alterations in health; and to develop health practices that promote and support optimal wellness. See Box 1-3 for an example of a question in this Client Needs category.
Box 1-
Health Promotion and Maintenance
The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this age?
- Puzzle
- Toy soldiers
- Large stacking blocks
- 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 independently, such as stacking blocks. Because toddlers do not have the developmental ability to determine what could be harmful, toys that are safe need to be provided. A puzzle and toy soldiers provide objects that can be placed in the mouth and may be harmful for a toddler. A card game with large pictures may require cooperative play, which is more appropriate for a school-age child.
Psychosocial Integrity
The Psychosocial Integrity category addresses content required to promote and support the ability of the client 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 experiencing stressful events 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.
Box 1-
Psychosocial Integrity
A client with end-stage chronic obstructive pulmonary disease has selected guided imagery to help cope with psychological stress. Which client statement indicates an understanding of this stress-reduction measure?
- “This will help only if I play music at the same time.”
- “This will work for me only if I am alone in a quiet area.”
- “I need to do this only when I lie down in case I fall asleep.”
- “The best thing about this is that I can use it anywhere, anytime.”
Answer: 4
This question addresses the Client Needs category Psychosocial Integrity and the content addresses coping mechanisms. Focus on the subject, a characteristic of guided imagery. 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 techniques or play music with it.
Physiological Integrity
The Physiological Integrity category includes 4 subcategories: Basic Care and Comfort, Pharmacological and Parenteral Therapies, Reduction of Risk Potential, and Physiological Adaptation. The NCSBN describes these subcategories as follows. Basic Care and Comfort addresses content for providing comfort and assistance to the client in the performance of activities of daily living. Pharmacological and Parenteral Therapies addresses content for administering medications and parenteral therapies, such as intravenous therapies and parenteral nutrition, and
Facial pain, personality changes, and ocular disturbances (photophobia, diplopia, light flashes, halos around bright objects, yellow or green color perception) are also signs of toxicity, but are not early signs.
Reduction of Risk Potential
A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. The nurse should implement which action to prepare the client for this test?
- Shave the groin for insertion of a femoral catheter.
- Remove all metal-containing objects from the client.
- Keep the client NPO (nothing by mouth) for 6 hours before the test.
- Instruct the client in inhalation techniques for the administration 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. Focus on the subject, preparing a client for an MRI. In an MRI study, radiofrequency pulses in a magnetic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, and watches, should be removed. In addition, a history should be taken to ascertain whether the client has any internal metallic devices, such as orthopedic hardware, pacemakers, or shrapnel. A femoral catheter is not used for this diagnostic test. An intravenous (IV) catheter may be inserted if a contrast agent is prescribed. Additionally, shaving is not a common practice because of the risk for microabrasions and infection. If needed, hair may be clipped away from a surgical or insertion site. NPO status is not necessary for an MRI study of the head. 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 mEq/L 1 mmol/L). On the basis of this laboratory result, the nurse interprets which sign as significant?
- Hyperpnea
- Drowsiness
- Hypertension
- Physical hyperactivity
Answer: 2 This question addresses the subcategory Physiological Adaptation in the Client Needs category Physiological Integrity. It addresses an alteration in body systems. Focus on the data in the question. The normal magnesium level is 1 to 2 mEq/L (0 to 1 mmol/L). A magnesium level of 3 mEq/L (1 mmol/L). indicates hypermagnesemia. Neurological manifestations begin to occur when magnesium levels are elevated and are noted as symptoms of neurological depression, such as drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia. Bradycardia and hypotension also occur.
Integrated Processes
The NCSBN identifies five processes in the test plan that are fundamental to the practice of nursing. These processes are incorporated throughout the major categories of Client Needs. The Integrated Process subcategories are Caring, Communication and Documentation, Nursing 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.
Box 1-
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?
- “Can you tell me what you understand about the procedure?”
- “Your fears are a sign that you really should have this procedure.”
- “Those are very normal fears, but please be assured that everything will be okay.”
- “Try not to worry. This is a well-known and easy procedure for the cardiologist.”
Answer: 1
This question addresses the subcategory Caring in the category of Integrated Processes. The correct option utilizes a therapeutic communication technique that explores the client’s feelings, determines the level of client understanding about the procedure, 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 by directing attention away from the client and toward the health care provider’s importance.
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); image (hot spot) questions; figure, chart/exhibit, or graphic option items; and audio or video item formats. You may also be administered some Next Generation NCLEX® (NGN) questions, which may be a part of the NCSBN research study. A pilot study on NGN questions is being conducted by the NCSBN, and results demonstrate that there is an asymmetrical relationship between knowledge and clinical judgment; thus, recall of learned material is not translating to safety and efficacy in practice. This is the impetus behind these new item types. Research on these new item types is still being conducted. The candidate will be informed if the
milliliters to administer one dose? Fill in the blank. Record your answer using one decimal place.
Answer: 19 mL
Formula:
In this question, you need to focus on the subject, mL per dose, and use the formula for calculating 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.
Multiple-Response Questions
For a multiple-response question, you will be asked to select or check all of the options, such as nursing interventions, that relate to the information in the question. In these question types, there may be 1 correct answer, there may be more than 1 correct answer, or all answers could be correct. 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.
Box 1-
Multiple-Response Question
The emergency department nurse is caring for a child suspected of acute epiglottitis. Which interventions apply in the care of the child? Select all that apply.
Obtain a throat culture.
Auscultate lung sounds.
Prepare the child for a chest x-ray.
Maintain the child in a supine position.
Obtain a pediatric-size tracheostomy tray.
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. Focus on the subject, interventions for the child with suspected acute epiglottitis. To answer this question, recall that acute epiglottitis is a serious obstructive inflammatory process that requires immediate intervention and that airway patency is a priority. Auscultating lung sounds allows the nurse to obtain information about airway patency without causing further airway compromise by examining the throat. Examination of the throat with a tongue depressor or attempting to obtain a throat culture is contraindicated because the examination can precipitate further 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 oxygenation status. Tracheostomy and intubation may be necessary if respiratory distress is severe. Remember to follow the specific directions given on the computer screen.
Ordered-Response Questions
In this type of question, you will be asked to use the computer 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 to the right side of the screen. Specific directions for moving the options are provided with the question. See Figure 1-1 for an example. These type of practice questions are located on the accompanying Evolve site.
- Places a nitroglycerin tablet under the client’s tongue
- Continues to monitor the client and then contacts the cardiologist
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 primary health care provider, cardiologist, 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 lifesaving treatment.
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 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.
Box 1-
Chart/Exhibit Question
The nurse reviews the history and physical examination documented in the medical record of a client requesting a prescription for oral contraceptives. The nurse determines that oral contraceptives are contraindicated because of which documented items? Refer to chart. Select all that apply.
Answer: Items 2, 3, 4, 11
This chart/exhibit question provides you with data from the client’s medical record. Focus on the subject, the item(s) that are a contraindication to the use of oral contraceptives. Oral contraceptives are contraindicated in women with a history of any of the following: thrombophlebitis and thromboembolic disorders, 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, pulmonary embolism, thrombotic stroke (or other types of strokes), myocardial infarction, and accelerations of preexisting breast tumors. Item 2 is a thromboembolic disorder with associated thrombophlebitis. Items 3 and 4 are cardiovascular diseases. The medications the client is taking are not specific
contraindications to oral contraceptives. The normal WBC is 5000-10,000 mm 3 (5-
× 10 9 /L). The normal Hgb for a male is 14-18 g/dL (140-180 mmol/L) and 12-16 g/dL (120-160 mmol/L) for a female. The normal Hct for a male is 42-52% (0.42-0) and
37-47% (0.37-0) for a female. The normal platelet count is 150,000-400,000 mm 3
(150-400 × 10 9 /L). Item 11 has components that are contraindicated; of note is that this client has polycythemia, which is a thromboembolic disorder and therefore is contraindicated for the use of oral contraceptives.
Graphic Item Option Questions
In this type of question, the option selections will be pictures rather than text. You will need to use the computer mouse to click on the option that represents your answer choice. See Box 1-11 for an example.
Box 1-
Graphic Item Option Question
The nurse should place the client in which position to administer an enema? (Refer to the figures in 1 to 4.)
1.
2.
3.
FIG. 1-2 Example of an audio question.
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. Content examples include, but are not limited to, assessment techniques, nursing procedures, or communication skills. Examples of this question type are located on the accompanying Evolve site (Fig. 1-3).
FIG. 1-3 Example of a video question.
Next Generation NCLEX (NGN) Item Types
These NGN question item types that may be used on the NCLEX exam can include, but are not limited to, CLOZE, enhanced multiple selection, enhanced hot spots, extended drag and drop, dynamic exhibits and constructed response, highlighting items, and matrix items. Additionally, case studies may accompany some question types. You are encouraged to access ncsbn for the most current information on these test items, their description, and how they will be presented. An enhanced multiple-response question is similar to a multiple-choice question in that it usually allows more than one option to be chosen. The difference is that an enhanced multiple-response question presents a long list of options. The NCLEX examination committee has not yet provided specific information as to how these question types will be presented. An example of one way they may be presented can be located in Box 1-12.
Box 1-
NGN Items: Case Study With Enhanced Multiple Response, CLOZE Item, Dynamic Exhibit, and Constructed Response Victoria Machane, 76 years old, is brought to the emergency department by her son, Michael. Michael tells the nurse that Victoria has not been able to tolerate any physical activity and that when she tries to do something she tires very easily. Victoria began to experience shortness of breath and a cough that started this morning, and Michael states that his mother’s skin looked pale and gray. On assessment, the nurse notes that Victoria exhibits shortness of breath on exertion;
Saunders Nclex Pyramid to Success
Course: Adult Health II (NUR 2211)
University: Hillsborough Community College
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