Saunders Q&A Review for NCLEX-RN Exam (2024) PDF

Instructions for online access How to Redeem additional online material included within the eBook: Your eBook purchase may include additional online-only materials associated with the title. An Elsevier eBook+ account is required in order to activate access. Please visit https://ebooks.health.elsev...

Instructions for online access How to Redeem additional online material included within the eBook: Your eBook purchase may include additional online-only materials associated with the title. An Elsevier eBook+ account is required in order to activate access. Please visit https://ebooks.health.elsevier.com/redeem-additional- content for instructions. Saunders Q & A Review for the NCLEX-RN® Examination NINTH EDITION Linda Anne Silvestri, PhD, RN, FAAN Nursing Instructor, University of Nevada, Las Vegas, Las Vegas, Nevada President and Owner, Nursing Reviews, Inc., Henderson, Nevada Director and Owner, Professional Nursing Seminars, Inc., Henderson, Nevada Elsevier, Next Generation NCLEX® (NGN) Consultant and Subject Matter Expert Angela Elizabeth Silvestri, PhD, APRN, FNP-BC, CNE Associate Professor and Associate Dean for Entry and Prelicensure Education, University of Nevada, Las Vegas, Las Vegas, Nevada President, Nurse Prep, LLC, Henderson, Nevada Associate Editors Eileen H. Gray, DNP, RN, CPNP Nursing Instructor, University of Nevada, Las Vegas, Las Vegas, Nevada Consultant, Nursing Reviews, Inc., Henderson, Nevada Allison E. Bowser, MEd, BSB Consultant, Nursing Reviews, Inc., Henderson, Nevada Table of Contents Instructions for online access Cover image Title page Copyright Dedication About the Authors Contributors Preface HTU Acknowledgments Unit I. NCLEX-RN® Preparation UNIT I. NCLEX-RN® Preparation Chapter 1. Clinical Judgment and the NCLEX-RN® Examination The Pyramid to Success The Examination Process Computer Adaptive Testing  Development of the Test Plan The Test Plan Types of Questions on the Examination and Scoring Registering to Take the Examination Authorization to Test Form and Scheduling an Appointment Changing Your Appointment The Day of the Examination Testing Accommodations Testing Center NGN Test Design Pass-or-Fail Decisions Completing the Examination Processing Results Candidate Performance Report Interstate Endorsement and Nurse Licensure Compact The International-Educated Nurse Chapter 2. Self-Efficacy and Profiles to Success The Pyramid to Success Profiles to Success: Increasing Self-Efficacy Developing Control  Confidence and Belief in Yourself Chapter 3. The NCLEX-RN® Examination: A Graduate’s Perspective A Note About The Next Generation NCLEX® (Ngn) from Madison Drew Mahon, BSN, RN CHAPTER 4. Clinical Judgment and Test-Taking Strategies Unit II. Client Needs UNIT II. Client Needs Chapter 5. Client Needs and the NCLEX-RN® Test Plan Physiological Integrity Safe and Effective Care Environment Health Promotion and Maintenance Psychosocial Integrity CHAPTER 6. Physiological Integrity Practice Questions CHAPTER 7. Safe and Effective Care Environment Practice Questions CHAPTER 8. Health Promotion and Maintenance Practice Questions CHAPTER 9. Psychosocial Integrity Practice Questions Unit III. Integrated Processes UNIT III. Integrated Processes CHAPTER 10. Integrated Processes and the NCLEX-RN® Test Plan Caring  Clinical Judgment Communication and Documentation Culture and Spirituality Nursing Process Teaching and Learning CHAPTER 11. Integrated Processes Practice Questions Caring Communication and Documentation Culture and Spirituality Teaching and Learning Nursing Process: Assessment Nursing Process: Analysis Nursing Process: Planning Nursing Process: Implementation Nursing Process: Evaluation References Copyright Elsevier 3251 Riverport Lane St. Louis, Missouri 63043 SAUNDERS Q&A REVIEW FOR THE NCLEX-RN® EXAMINATION, ISBN: 978-0-323-93057-4 NINTH EDITION Copyright © 2024 by Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2021, 2018, 2015, 2012, and 2009. NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc. Content Strategist: Heather Bays-Petrovic Director of Content Development: Laurie Gower Senior Content Development Specialist: Rebecca Leenhouts Publishing Services Manager: Julie Eddy Senior Project Manager: Cindy Thoms Senior Book Designer: Maggie Reid Printed in India Last digit is the print number: 9 8 7 6 5 4 3 2 1 Dedication In loving memory of Linda’s parents and Angela’s grandparents, ARNOLD LAWRENCE AND FRANCES MARY Our memories of their love, support, and words of encouragement will remain in our hearts forever! About the Authors Linda Anne Silvestri Photo by Laurent W. Valliere Linda is a well-known author, nurse educator, entrepreneur, and philanthropist whose professional aspirations focus on assisting nursing students to become successful. She has been teaching at all levels of nursing education for many years. Linda is currently a nursing instructor and nursing course developer at the University of Nevada, Las Vegas (UNLV). She earned her PhD in Nursing from UNLV and conducted research on self-efficacy and the predictors of NCLEX® success. Her research findings are published in the Journal of Nursing Education and Practice. Dr. Silvestri has received several awards and honors. In 2019 she was inducted as a Fellow in the American Academy of Nursing. In 2012 she received the UNLV School of Nursing Alumna of the Year Award. And in 2010 she received the School of Nursing’s Certificate of Recognition for Outstanding PhD Student. Linda is a member of several national nursing organizations, including the Honor Society of Nursing, Sigma Theta Tau International, the National League for Nursing, the America Nurses Association, Phi Kappa Phi, the Western Institute of Nursing, and the Golden Key International Honour Society. Additionally, she is a Fellow in the American Academy of Nursing and will be inducted as a Fellow in the National League for Nursing Academy of Nursing Education in the Fall of 2023. Dr. Silvestri is the successful Elsevier author of numerous best-selling national and international NCLEX® preparation resources. She is also co-author of Strategies for Student Success on the Next Generation NCLEX® (NGN) and serves as an Elsevier Thought Leader and Subject Matter Expert for the Next Generation NCLEX® (NGN). Linda has presented numerous faculty and student webinars on NCLEX® and NGN preparation and success. She is the President and Owner of Nursing Reviews, Inc., and Director and Owner of Professional Nursing Seminars, Inc. Both companies are dedicated to helping nursing students and graduates achieve their goals of becoming licensed nurses. Angela Elizabeth Silvestri  Angela is a well-known nurse educator, researcher, and author. She has been teaching and working in university administrative roles for many years at all levels of nursing education. She has experience teaching in classroom and clinical settings and in working with graduate students on their culminating projects and research dissertations. She currently serves as the Associate Dean for Entry and Prelicensure Education at the University of Nevada, Las Vegas (UNLV). Dr. Silvestri is a successful Elsevier author of numerous best-selling NCLEX® preparation resources on the national and international levels. She also serves as an Elsevier Subject Matter Expert for the Next Generation NCLEX® (NGN). Angela earned her bachelor’s degree in nursing and in sociology from Salve Regina University in Newport, Rhode Island; she earned her master’s degree with a focus in nursing education and her PhD from the University of Nevada, Las Vegas. She also has a post- master’s graduate certificate in advanced practice and is a board- certified family nurse practitioner. She is a scholar in Sigma Theta Tau’s New Academic Leadership Academy. Dr. Silvestri is passionate about college students’ success. She works with faculty, staff, and students on managing primary and episodic health care needs at UNLV’s Student Wellness Center and Faculty and Staff Treatment Center as a family nurse practitioner. This passion also comes through in her work at the School of Nursing, where she teaches medical-surgical nursing and pharmacology, and in the publication of her research and best-selling licensure exam review resources at the national and international levels. Contributors CONSULTANTS Dianne E. Fiorentino, Research Coordinator, Nursing Reviews, Inc., Henderson, Nevada Karen Hoem, Editorial and Reviewer Consultant, Nurse Prep, LLC, Henderson, Nevada Katherine M. Silvestri, MSN, APRN, FNP-BC Family Nurse Practitioner, Student Health Center, University of Nevada, Las Vegas, Las Vegas, Nevada Editorial and Reviewer Consultant, Nursing Reviews, Inc., Henderson, Nevada CONTRIBUTORS Natalie Filer, BSN, RN , Level IV Neonatal Intensive Care Unit Nurse, Children’s Memorial Hermann Hospital, Houston, Texas James Guibault Jr. BS, PharmD Clinical Pharmacist, Orlando, Florida Pharmacology Consultant, Nursing Reviews, Inc., Henderson, Nevada Madison Drew Mahon, BSN, RN , Neonatal ICU Registered Nurse, St. Luke’s of Nampa Idaho, Nampa, Idaho Laurent W. Valliere, BS, DD , Vice President, Nursing Reviews, Inc., Henderson, Nevada Preface “Success is climbing a mountain, facing the challenge of obstacles, and reaching the top of the mountain.” Linda Anne Silvestri, PhD, RN, FAAN “Success is never an accident. To be successful is to have been perseverate, to have sacrificed, and to have loved what you are cultivating to become successful.” Angela Elizabeth Silvestri, PhD, APRN, FNP-BC, CNE Welcome to Saunders Pyramid to Success! An Essential Resource for Test Success Saunders Q&A Review for the NCLEX-RN® Examination is one in a series of products designed to assist you in achieving your goal of becoming a registered nurse. This text and Evolve site package provide you with more than 6000 practice NCLEX-RN test questions based on the current NCLEX-RN test plan. The current test plan for the NCLEX-RN identifies a framework based on Client Needs. The Client Needs categories include Physiological Integrity, Safe and Effective Care Environment, Health Promotion and Maintenance, and Psychosocial Integrity. Integrated Processes are also identified as a component of the test plan. These include Caring, Clinical Judgment, Communication and Documentation, Culture and Spirituality, Nursing Process, and Teaching and Learning. This book has been uniquely designed and includes chapters that describe each specific component of the NCLEX-RN test plan framework and five practice tests that contain NCLEX-style questions specific to each component. NCLEX-RN® Test Preparation This book begins with information regarding NCLEX-RN preparation. Chapter 1 , Clinical Judgment and the NCLEX-RN® Examination, addresses information about clinical judgment and the related cognitive processes/skills as defined by the National Council of State Boards of Nursing (NCSBN) and all of the information related to the NCLEX-RN test plan and the examination testing procedures. This chapter answers all of the questions that you may have regarding this information. Chapter 2 , Self-Efficacy and Profiles to Success, discusses the NCLEX-RN from a nonacademic viewpoint and emphasizes a holistic approach for your individual test preparation. This chapter discusses self-efficacy, the components of a structured study plan, anxiety- reducing techniques, and personal focus issues. Nursing students also want to hear what other students have to say about their experiences with the NCLEX-RN and what it is really like to take this examination. Chapter 3 , The NCLEX-RN® Examination: A Graduate’s Perspective, is a story of success written by a nursing graduate who recently took the NCLEX-RN and addresses the issue of what the examination is all about. Chapter 4 , Clinical Judgment and Test-Taking Strategies, includes information about using clinical judgment and the six cognitive processes/skills to answer questions and all of the strategies that will assist in teaching you how to read a question, how not to read into a question, and how to use the process of elimination and various other strategies to select the correct response from the options presented. Client Needs Chapters 5 through 9 address the NCLEX-RN test plan component, Client Needs. Chapter 5 , Client Needs and the NCLEX-RN® Test Plan describes each category of Client Needs as identified by the test plan and lists any subcategories, the percentage of test questions for each category, and some of the content included on the NCLEX-RN. Chapters 6 through 9 contain practice test questions related specifically to each category of Client Needs. Chapter 6 comprises questions related to Physiological Integrity; Chapter 7 contains questions dealing with Safe and Effective Care Environment; Chapter 8 is made up of questions concerned with Health Promotion and Maintenance; and Chapter 9 contains Psychosocial Integrity questions. Integrated Processes Chapters 10 and 11 address the Integrated Processes as identified in the NCLEX-RN test plan. Chapter 10 , Integrated Processes and the NCLEX-RN® Test Plan, describes each Integrated Process. Chapter 11 contains practice test questions related specifically to each Integrated Process, including Caring, Communication and Documentation, Culture and Spirituality, Nursing Process, and Teaching and Learning. Clinical Judgment is addressed with practice questions. Special Features of the Book Book Design The book is designed with a unique two-column format. The left column presents the practice questions, answer options, and coding areas, while the right column provides the corresponding answers, rationales, priority nursing tips, test-taking strategies, and references. The two-column format makes the review easier because you do not have to flip through pages in search of answers and rationales. A bookmark accompanies this book, and you can use it to hide the right column with the answer section as you are practicing questions. Special Features Found on Evolve Pretest and Study Calendar The accompanying Evolve site contains a pretest that provides you with feedback on your strengths and weaknesses. The results of your pretest will generate an individualized study calendar to guide you in your preparation for the NCLEX examination. A post-test is generated after the pretest is taken and is intended to be completed after using other features of the product. Heart, Lung, and Bowel Sound Questions The accompanying Evolve site contains Audio Questions representative of content addressed in the current test plan for the NCLEX-RN exam. These questions are in NCLEX-style format, and each question presents an audio sound as a component of the question. Podcasts The companion Evolve site includes three Podcasts, which cover challenging subject areas under the current NCLEX-RN test plan, including Pharmacology, Acid-Base Balance, and Fluids and Electrolytes. Information on accessing the podcasts is located in Chapter 4. Next Generation NCLEX® (NGN) Case Studies and NGN Test Questions The accompanying Evolve site contains single-episode case studies and unfolding case studies. These case studies are accompanied by NGN test questions representative of the NGN testing format. The single-episode case studies are accompanied by one NGN test question that measures one of the cognitive processes/skills of the NCSBN Clinical Judgment Measurement Model (NCJMM). The unfolding case studies are accompanied by six NGN test questions, and the questions measure all six cognitive processes/skills of the NCJMM. These cognitive processes/skills include Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take Action, and Evaluate Outcomes. Practice Questions Multiple Choice and Alternate Item Format Questions While preparing for the NCLEX-RN, students need to review practice test questions. This book contains practice questions that are in the multiple choice format or in alternate item test question formats used in the NCLEX-RN examination. The accompanying Evolve site contains more than 6000 questions: all the questions from the book, plus new questions, including all types of alternate item formats. The alternate item format questions in the book and on the accompanying Evolve site may be presented as one of the following: Fill-in-the-blank question Multiple response question (select all that apply) Prioritizing (ordered response) question Figure/illustration question Graphic options question, in which each option contains a figure or illustration Scenario/exhibit question Audio question that includes a heart, lung, or bowel sound NGN® Case Studies and NGN test questions These questions provide you with practice in prioritizing, decision- making and critical thinking, and strengthening your clinical judgment skills. In addition, each practice question provides a review button that links you to common laboratory values for your reference while studying on the Evolve site. Answer Sections for Practice Questions Each practice question is accompanied by the correct answer, rationale, priority nursing tip, test-taking strategy, question categories, and reference source. The structure of the answer section is unique and provides the following information for every question: Rationale: The rationale provides you significant information regarding both correct and incorrect options.  Priority Nursing Tip: The priority nursing tip provides you with an important piece of information that will be helpful to you when answering practice questions and questions on the NCLEX. Test-Taking Strategy: The test-taking strategy provides a logical path for selecting the correct option and helps you select an answer to a question for which you otherwise might have to guess. In each practice question, the specific strategy that will assist in answering the question correctly is highlighted in bold blue type. The highlighted specific test- taking strategies in the practice questions will guide you on what topics to review for further remediation in Saunders Clinical Judgment and Test-Taking Strategies: Passing Nursing School and the NCLEX® Exam, Saunders Comprehensive Review for the NCLEX-RN® Exam, and the Saunders/HESI Online Review for the NCLEX-RN® Exam. Question Categories: Each question on the accompanying Evolve site is identified based on the categories used by the NCLEX-RN test plan. Both Content Area and Health Problem categories are also provided with each question to assist you in identifying areas in need of review. In addition, Priority Concepts codes are included, which provide the specific concept related to nursing practice. This code is especially helpful to students learning in a concept-based curriculum. The categories identified with each question include Level of Cognitive Ability, Client Needs, Clinical Judgment/Cognitive Skill, Integrated Process, Content Area, Health Problem, and Priority Concepts. All categories are identified by their full names so that you do not need to memorize codes or abbreviations. Reference: The reference source and page number are listed for you so that you can easily find the information you need to review in your undergraduate nursing textbooks. How to Use This Book Saunders Q&A Review for the NCLEX-RN® Examination is specially designed to help you with your successful journey to the peak of the Pyramid to Success: becoming a registered nurse. As you begin your journey through this book, you will be introduced to all of the important points regarding the NCLEX-RN examination, the process of testing, and the unique and special tips regarding how to prepare yourself both academically and nonacademically for this important examination. Read the chapter from the nursing graduate who recently passed the NCLEX-RN and consider what the graduate had to say about the examination. The test-taking strategy chapter will provide you with important strategies that will guide you in applying clinical judgment and selecting the correct option(s). Read this chapter and practice these strategies as you proceed through your journey with this book. Once you have read the introductory components of this book, it is time to begin the practice questions. As you read through each question and select an answer, be sure to read the rationale, the priority nursing tip, and the test-taking strategy. The rationale provides significant information regarding both the correct and incorrect options. The priority nursing tip provides a piece of important information to remember that will help answer questions on the NCLEX, and the test-taking strategy provides the logic for selecting the correct option. Use the reference source provided so that you can easily find the information you need to review. Climbing the Pyramid to Success This step on the Pyramid to Success is to get additional practice with a Q&A review product. Saunders Q&A Review for the NCLEX- RN® Examination offers more than 6000 unique practice questions in the book and on the companion Evolve site. The questions are focused on the Client Needs and Integrated Processes of the NCLEX test plan, making it easy to access your study area of choice. As you work your way through Saunders Q&A Review for the NCLEX-RN® Examination and identify your areas of strength and weakness, you can return to the companion book, Saunders Comprehensive Review for the NCLEX-RN® Examination, to focus your study on these areas. The purpose of the Saunders Comprehensive Review for the NCLEX-RN® Examination is to provide a comprehensive review of the nursing content you will be tested on during the NCLEX-RN examination. However, Saunders Comprehensive Review for the NCLEX-RN® Examination is intended to do more than simply prepare you for the rigors of the NCLEX; this book is also meant to serve as a valuable study tool that you can refer to throughout your nursing program, with customizable Evolve site selections to help identify and reinforce key content and health problem areas. Your final step on the Pyramid to Success is to master the online review. HESI/Saunders Online Review for the NCLEX-RN® Examination provides an interactive and individualized platform to get you ready for your final licensure exam. This online course provides 10 high-level content modules, supplemented with instructional videos and accompanying NGN test items, animations, audio, illustrations, case studies, and several subject matter exams. End-of-module practice tests are provided along with several Crossing the Finish Line: Practice Tests and three Test Yourself Quizzes. In addition, you can assess your strengths and areas in need of improvement with a pretest that generates a study calendar providing guidance on how to proceed through the course and a comprehensive exam in a computerized environment that prepares you for the actual NCLEX-RN exam. At the base of the Pyramid to Success are our test-taking strategies, which provide a foundation for understanding and unpacking the complexities of NCLEX exam questions, including alternate item formats and NGN test items. Saunders Clinical Judgment and Test-Taking Strategies: Passing Nursing School and the NCLEX® Exam takes a detailed look at all the test-taking strategies you will need to know to pass any nursing examination, including the NCLEX. Special tips are integrated for nursing students, and there are more than 1200 practice questions included so that you can apply the testing strategies. To obtain any of these resources that will prepare you for your nursing exams and the NCLEX-RN exam, visit the Elsevier Health Sciences website: www.elsevierhealth.com. You can also visit the Apple App Store and Google Play to locate the app for both this resource and the Saunders Comprehensive Review for the NCLEX- RN® Examination.  Good luck with your journey through the Saunders Pyramid to Success. We wish you continued success throughout your new career as a Registered Nurse! Linda Anne Silvestri, PhD, RN, FAAN Angela Elizabeth Silvestri, PhD, APRN, FNP-BC, CNE HTU To All Future Registered Nurses, Congratulations to you! You should be very proud of and pleased with yourself for your accomplishments in nursing, as well as for your well-deserved success in completing your nursing program to become a registered nurse. We know you have worked very hard to be successful and that you have proven to yourself that indeed you can achieve your goals. You are about to enter what is, in our opinion, the most wonderful and rewarding profession. Your willingness, desire, and ability to assist those who need nursing care will bring you great satisfaction. In the profession of nursing, learning is a lifelong process, which makes the profession stimulating and dynamic and ensures that your learning will continue to expand and grow as the profession continues to evolve. Your next very important endeavor will be the learning process needed to achieve success in your examination to become a registered nurse. We are excited and pleased to be able to provide you with the Saunders Pyramid to Success products, which will help you prepare for your next important professional goal: becoming a registered nurse. We want to thank all of our former nursing students whom we have assisted in studying for the NCLEX-RN exam for their willingness to offer ideas for preparing for licensure. Student input certainly is a unique benefit to all of the products available in the Saunders Pyramid to Success. Saunders Pyramid to Success products provide you with everything that you need to ready yourself for the NCLEX-RN exam. These products include material that is required for the NCLEX-RN exam for all nursing students regardless of educational background, specific strengths, areas in need of improvement, or clinical experience during the nursing program. So let’s get started and begin our journey through the Saunders Pyramid to Success, and welcome to the wonderful profession of nursing! Sincerely, Linda Anne Silvestri, PhD, RN, FAAN Angela Silvestri, PhD, APRN, FNP-BC, CNE Acknowledgments A Few Words From Linda There are many individuals who, in their own ways, have contributed to my success in making my professional dreams become a reality. I extend my sincere appreciation and warmest thanks to all of them. First, I want to acknowledge my parents, who opened my door of opportunity in education and encouraged and supported me through my profession to work hard to reach my goals. I thank my mother, Frances Mary, for all of her love, support, and assistance as I continuously worked to achieve my professional goals. I thank my father, Arnold Lawrence, who always provided insightful words of encouragement. I miss you both so dearly, and my memories of your love and support will always remain in my heart. I also thank my best friend and the love of my life, my husband, Larry, for always being there for me for whatever I needed; my sister, Dianne Elodia, and her husband, Lawrence, and my brother, Lawrence Peter, and my sister-in-law, Mary Elizabeth, for all their love and continuous support. And I thank all my nieces and nephews, who were continuously supportive, giving, and helpful during my research and preparation of this publication. But I especially want to thank my niece and co-author, Angela, for her love and continuous support and for always being there when I need her. I want to thank my nursing students at the Community College of Rhode Island who approached me in 1991 and persuaded me to assist them in preparing to take the NCLEX-RN examination. Their enthusiasm and inspiration led to the commencement of my professional endeavors in conducting review courses for the NCLEX- RN exam and writing NCLEX preparation resources for nursing students. I also thank the numerous nursing students who have attended my review courses for their willingness to share their needs and ideas. Their input has certainly added a special uniqueness to this publication. I wish to acknowledge all of the nursing faculty who taught in my review courses for the NCLEX-RN exam. Their commitment, dedication, and expertise have certainly assisted nursing students in achieving success with the NCLEX-RN exam. Additionally, I want to especially acknowledge my husband, Larry (Laurent W. Valliere), for his contribution to this publication, for teaching in my review courses for the NCLEX-RN exam, and for his commitment and dedication in assisting my nursing students to prepare for the exam from a nonacademic point of view. I also want to extend a very special thank you to my niece, Angela, for joining me in preparing and authoring these NCLEX resources. Angela is so wonderful to work with. Her ideas and her expertise have certainly added to the content of this publication and all of our NCLEX publications. She is dedicated to promoting and ensuring student success. Thank you, Angela! And finally, I again want to thank my husband, Larry, for all of his continuous support as I moved through my personal challenges and professional endeavors; he has been my rock of support! A Few Words From Angela There are many people that contributed to my success in my work on this product. I am very grateful for their continued support in all of my endeavors. First and foremost, I would like to thank my husband, Brent, for his lighthearted and positive attitude. He always knows how to make me laugh, especially when I’m stressed. All of this would not be possible without him! I would also like to thank my parents, Mary and Larry, for their continued support throughout the years. Their words of encouragement and wisdom have been tremendously important to my success. I also don’t know what I would do without their support in caring for my kids!  I would like to thank my sister, Katie, who is a wonderful nurse. Her ambitions as a nursing student are inspiring and remind me every day about why I’m so passionate about being an educator. Thank you to my brother, Nick, who always is positive and encouraging about my work. His wit and sarcasm are always a great way to lift my mood at the end of the day. I want to extend a special thank you to Linda for her collaboration, guidance, and expertise. Without her, I would not be where I am today. Thank you, Linda! A Few Words From Both Linda and Angela We want to thank our Associate Editors, Eileen Gray and Allison Bowser, for all of their dedication and hard work in editing and preparing the entire manuscript for this edition. Their expertise and close attention to detail have certainly added to the quality of this resource. Eileen and Allison, thank you so much! We also want to acknowledge and thank Laurent W. Valliere for writing a chapter addressing important nonacademic test preparation issues. In addition, we also sincerely thank Natalie Filer, RN, BSN and Madison Drew Mahon, BSN, RN, for writing a chapter for this book about their experience preparing for and taking the NCLEX-RN examination. A special thank you and acknowledgment also go to all of the previous contributors who provided contributions to this book. And a very special thank you goes to Katherine Silvestri, MSN, APRN, FNP-BC, CNE, for her work in reviewing, editing, and coding practice questions. We especially thank Dianne E. Fiorentino for her continuous and endless support and dedication to our work and in her reference support and other secretarial responsibilities for the ninth edition of this book. As well, we thank Karen Hoem for her continuous and endless support and dedication to our work and for all of her expert organizational skills, review, and editing. We thank Jimmy Guibault for reviewing all of the medication questions and providing medication research support. We sincerely acknowledge and thank some very important and special people from Elsevier. We thank Heather Bays-Petrovic, Content Strategist, for her continuous support, enthusiasm, and expert professional guidance throughout the preparation of this edition. Thank you, Heather—you are the best! We could not have completed this publication without you! A very special thank you goes to Cindy Thoms, Senior Project Manager, for her expert work and for anticipating our needs as we prepared this publication. We worked so closely with Cindy throughout the preparation and publication and could not have done it without her expert help and her support and patience with us. Thank you, Cindy! We also extend a special thank you to Jenny Korte, our copyeditor and proofreader, for her superior work and for paying such close attention to detail in the manuscript. And a very special thank you goes to Rebecca Leenhouts, Senior Content Development Specialist, who provided us with consistent and a tremendous amount of support throughout this publication. Thank you, Rebecca, for maintaining order for all of the work that we submitted for manuscript production. We want to acknowledge all of the staff at Elsevier for their tremendous help throughout the preparation and production of this publication. A special thanks goes to all of them. We thank Julie Eddy, Publishing Services Manager; Cindy Thoms, Senior Project Manager; and Maggie Reid, Design Direction. You have all played such significant roles in finalizing this publication. Last, a very special thank you to all our nursing students: past, present, and future. All of you light up our lives! Your love and dedication to the profession of nursing and your commitment to provide health care will bring never-ending rewards! UNIT I NCLEX-RN® Preparation OU T LI NE UNIT I. Introduction Chapter 1. Clinical Judgment and the NCLEX-RN® Examination Chapter 2. Self-Efficacy and Profiles to Success Chapter 3. The NCLEX-RN® Examination: A Graduate’s Perspective CHAPTER 4. Clinical Judgment and Test-Taking Strategies UNIT I NCLEX-RN® Preparation Chapter 1 Clinical Judgment and the NCLEX-RN® Examination 2 Chapter 2 Self-Efficacy and Profiles to Success 13 Chapter 3 The NCLEX-RN® Examination: A Graduate’s Perspective 17 Chapter 4 Clinical Judgment and Test-Taking Strategies 19 Chapter 1: Clinical Judgment and the NCLEX-RN® Examination The Pyramid to Success Welcome to Saunders Q&A Review for the NCLEX-RN® Examination, the second component of the Pyramid to Success! At this time, you have completed your first path toward the peak of the pyramid with Saunders Comprehensive Review for the NCLEX- RN® Examination. Now it is time to continue that journey to become a registered nurse with Saunders Q&A Review for the NCLEX-RN® Examination. As you begin your journey through this book, you will be introduced to all of the important points regarding the NCLEX-RN examination, including the process of testing and unique and special tips for preparing yourself both academically and nonacademically 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 guide you in selecting the correct option, assist you in making an educated guess if you are not entirely sure about the correct answer, and guide you in ways to answer the Next Generation NCLEX® (NGN) test items. Additionally, the Cognitive Skills presented in the National Council of State Boards of Nursing (NCSBN) Clinical Judgment Measurement Model (NCJMM) are identified in practice questions. About This Resource Saunders Q&A Review for the NCLEX-RN® Examination contains more than 6000 NCLEX-style practice questions. Question types include multiple choice; multiple response (select all that apply [SATA]); fill in the blank; prioritizing (ordered response); image (“hot spot”) questions; scenario/exhibit questions; graphic options; and audio questions. The Evolve site also includes podcasts for audio review on test-taking strategies for pharmacology, fluids and electrolytes, and acid-base balance. NGN-style questions are also included on the Evolve site. The chapters in the book have been developed to provide a description of the components of the NCLEX- RN test plan, including Client Needs and the Integrated Processes. In addition, chapters have been prepared to contain practice questions specific to each category of Client Needs and the Integrated Processes. A rationale, priority nursing tip, test-taking strategy, and reference source containing a page number are provided with each question. Each question is coded on the basis of the Level of Cognitive Ability, Client Needs category, Integrated Process, Content Area being tested, Health Problem if applicable, and the Cognitive Skills/Processes of the National Council of State Boards of Nursing (NCSBN) Clinical Judgment Measurement Model (NCJMM). In addition, two Priority Concepts that relate to the content of the question are identified. This code is helpful specifically for students whose curriculum is concept based. The rationale contains significant information regarding both the correct and incorrect options. The priority nursing tip provides key information to remember about a nursing point. The test-taking strategy maps out a logical path for selecting the correct option, if necessary. The reference source and page number provide easy access to the information that you need to review. The Health Problem code is a unique and helpful feature that allows you to filter and select questions based on a disease process when you are practicing questions on Evolve. For example, if heart failure is your area of interest, you can select “Adult Health, Cardiovascular, Heart Failure” on the Evolve site, and all questions on this content will be generated for practice. 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 Comprehensive Review for the NCLEX-RN® Examination, Saunders Clinical Judgment and Test-Taking Strategies: Passing Nursing School and the NCLEX® Exam, Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items, The HESI/Saunders Online Review for the NCLEX-RN® Examination, Saunders Q&A Review Cards for the NCLEX-RN® Exam, and Saunders RNtertainment for the NCLEX-RN® Examination Review Game. The HESI® CompassTM Course is also a resource for NCLEX preparation and provides you with an individual coach to guide you in your preparation. Ask your nursing instructors about institutional access to this course. 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 http://elsevierhealth.com or by calling 1-800-545-2522. Let’s begin our journey through the Pyramid to Success. Clinical Judgment Clinical judgment is the observed outcome of critical thinking and decision-making (Dickison, Haerling, & Lasater, 2019). In recent years, heightened attention has been paid to clinical judgment as a means of teaching, learning, and assessment and testing. The Next Generation NCLEX-RN examination requires candidates to demonstrate a higher level of ability in applying clinical judgment in the delivery of client care. Clinical judgment can also be used as a test-taking strategy to answer test questions (see Chapter 4). The NCSBN has created a Clinical Judgment Measurement Model (NCJMM) that consists of applying six cognitive skills or processes. These include: (1) recognizing cues; (2) analyzing cues; (3) prioritizing hypotheses; (4) generating solutions; (5) taking actions; and (6) evaluating outcomes (Dickison et al., 2019). Table 1.1 provides a description of these six cognitive skills/processes identified in the NCJMM. The NCJMM also serves as a guide for the NCSBN to create NGN questions. The NGN was launched in April 2023. Scored stand-alone test items (Bowtie and Trend items) and unfolding case studies are presented in the NGN. Some of these NGN item types can be found on the Evolve site accompanying this book, and an example of an NGN item is located in Chapter 4, Box 4.26. We strongly encourage you to frequently access the NCSBN website at https://www.ncsbn.org for updates. The 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 website (http://www.ncsbn.org) and from the NCSBN 2023 test plan for the NCLEX-RN. It includes some procedures related to registering for the examination, testing procedures, and the answers to the questions most commonly asked by nursing students and graduates preparing to take the NCLEX-RN. You can obtain additional information regarding the test and its development by accessing the NCSBN website and clicking on the NCLEX® & Other Exams 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 website, because this site provides you with valuable information about the NCLEX, the test plan, 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. TABLE 1.1 Cognitive Skills/Processes and Descriptions Cognitive Description Skill/Process Recognize Identifying significant data; data can be from cues many sources (assessment) Analyze cues Connecting data to the client’s clinical presentation—determining if the data is expected? Unexpected? (analysis) Prioritize Ranking hypotheses; what are the concerns or hypotheses client needs/problems and their priority? (analysis) Generate Using hypotheses or client needs to determine solutions interventions for an expected outcome (planning) Take actions Implementing the generated solutions addressing the highest priorities or hypotheses (implementation) Evaluate Comparing observed outcomes with expected outcomes ones (evaluation) From: Dickison, P., Haerling, K.A., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical Judgment Model into Nursing Educational Frameworks, Journal of Nursing Education, 58 (2), 72–78. Computer Adaptive Testing The acronym CAT stands for computerized adaptive test, which means that the examination is created as the test-taker answers each question. All the test questions are categorized on the basis of the test plan structure and the level of difficulty of the question. As you answer a question, the computer determines your competency based on the answer you selected. If you selected a correct answer, the computer scans the question bank and selects a more difficult question. If you selected an incorrect answer, the computer scans the question bank and selects an easier question. This process continues until all test plan requirements are met and a reliable pass-or-fail decision is made. When you take a CAT, once an answer is recorded, all subsequent questions administered depend, to an extent, on the answer selected for that question. Skipping and returning to earlier questions are not compatible with the logical methodology of a CAT. The inability to skip questions or go back to change previous answers will not be a disadvantage to you; you will not fall into that “trap” of changing a correct answer to an incorrect one with the CAT system. If you are faced with a question that contains unfamiliar content, you may need to guess at the answer. Although guessing is discouraged when taking any examination, there is no penalty for guessing on the NCLEX. Remember, in almost all of the questions, the answer will be right there in front of you. If you need to guess, use your nursing knowledge, clinical experiences, and clinical judgment skills to their fullest extent and all of the test-taking strategies you have practiced in this review program. Refer to Chapter 4 for information on clinical judgment and test-taking strategies. You do not need any computer experience to take this examination. A keyboard tutorial is provided and administered to all test-takers at the start of the examination. The tutorial provides instructions for the use of the on-screen optional calculator and the mouse and for recording an answer. The tutorial provides instructions on how to respond to all question types on this examination. This tutorial is on the NCSBN website; you are encouraged to view the tutorial when you are preparing for the NCLEX examination. In addition, at the testing site, a test administrator is present to assist in explaining the use of the computer to ensure your full understanding of how to proceed. The CAT model will not be used for the NGN items. Instead, the NCSBN will be using selected scoring models that will be applied to your test responses. In addition, you will not be able to skip NGN questions or return to earlier questions. For specific information on the scoring models, refer to the NCSBN website at https://www.ncsbn.org and the National Council of State Boards of Nursing 2021 Next Generation NCLEX News at https://www.ncsbn.org/public- files/NGN_Summer21_ENG.pdf. Development of the Test Plan The test plan for the NCLEX-RN examination is developed by the NCSBN. The examination is a national examination; the NCSBN considers the legal scope of nursing practice as governed by state laws and regulations, including the Nurse Practice Act, and uses these laws to define the areas on the examination that will assess the competence of the test-taker for licensure. The NCSBN also conducts an important study every 3 years, known as a practice analysis study. The results of this study determine the framework for the test plan for the examination. The participants in this study include newly licensed registered nurses from all types of generalist nursing education programs. Participants of this study provide valuable information about work settings. From a list of nursing care activities (activity statements) provided, the participants are asked about the applicability, frequency, and importance of performing these activities in relation to client safety. A panel of content experts at the NCSBN analyze the results of the study and make decisions regarding the test plan framework. The results of this recently conducted study provided the structure for the test plan implemented in April 2023. The Test Plan The content of the NCLEX-RN examination reflects the activities identified in the practice analysis study conducted by the NCSBN. Exam questions are written based on the test plan framework and these activities rather than on content areas such as adult health, maternity, pediatrics, and mental health. The questions 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 remembering, understanding, applying, analyzing, evaluating, and creating. The practice of nursing requires complex thought processing and critical thinking in decision-making and in making clinical judgments. Therefore, you will not encounter any remembering or understanding questions on the NCLEX. Table 1.2 provides descriptions and examples of each level of cognitive ability. Box 1.1 presents an example of an applying question. Client Needs In the test plan implemented in April 2023, the NCSBN applied a test plan framework based on Client Needs. The NCSBN identifies four major categories of Client Needs, which are Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity. Some of these categories are further divided into subcategories. Refer to Chapter 5 for a detailed description of the categories of Client Needs and the NCLEX-RN examination, and refer to Table 1.3 for the percentages of questions from each Client Needs category. TABLE 1.2 Levels of Cognitive Ability: Descriptions and Examples Level Description and Example Remembering Recalling, retrieving information from memorization, previous learning, or long-term memory Example: A normal blood glucose level is 70–99 mg/dL (3.9–5.5 mmol/L). Understanding Determining the meaning of information Example: A blood glucose level of 60 mg/dL (3.34 mmol/L) is lower than the normal reference range. Applying Carrying out an appropriate action based on information Example: Administering 10–15 g of carbohydrate such as a ½ glass of fruit juice to treat mild hypoglycemia Analyzing Examining concepts or data and interpreting how the concepts or data connect or relate to one another Example: The concept is mild hypoglycemia and the connecting data are the signs and symptoms of mild hypoglycemia, such as hunger, irritability, weakness, headache, blood glucose level lower than 70 mg/dL (3.9 mmol/L). 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 70–99 mg/dL (3.9–5.5 mmol/L)  Level Description and Example Creating Generating or producing a new outcome or plan of care 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 Adapted from: Understanding Bloom’s (and Anderson and Krathwohl’s) Taxonomy, 2015, ProEdit, Inc. http://www.proedit.com/understanding-blooms-and- anderson-and-krathwohls-taxonomy/ Integrated Processes The NCSBN identifies six processes in the test plan that are foundational to the practice of nursing. These processes are incorporated throughout the major categories of Client Needs. The Integrated Process subcategories are Caring, Clinical Judgment, Communication and Documentation, Culture and Spirituality, Nursing Process (Assessment, Analysis, Planning, Implementation, and Evaluation), and Teaching and Learning. Refer to Chapter 10 for a detailed description of the Integrated Processes and the NCLEX- RN examination. Types of Questions on the Examination and Scoring The types of questions on the current NCLEX include multiple choice; fill-in-the-blank; multiple response; ordered response (prioritizing); image (hot spot) questions; figure, scenario/exhibit, or graphic option items; and audio formats. These question types will continue to be a part of the NCLEX examination, and, except for the multiple response questions, each of these question types will be scored as either correct or incorrect, known as dichotomous scoring. No partial credit is given. Thus, the possible points for these question types will be 0 or 1 point. Partial credit will be given for the multiple response questions. TABLE 1.3 From: National Council of State Boards of Nursing. (2023). Next Generation NCLEX® , NCLEX-RN test plan, National Council of State Boards of Nursing. BOX 1. 1 Le v e l o f C ognit ive A b ility : A p p ly ing A client at 32 weeks’ gestation is brought into the emergency department after an automobile crash. The client is bleeding vaginally, and fetal assessment indicates moderate fetal distress. Which action would the nurse take first in an attempt to reduce the stress on the fetus? 1. Start intravenous (IV) fluids at a keep open rate. 2. Set up for an immediate cesarean section delivery. 3. Elevate the head of the bed to a semi-Fowler’s position. 4. Administer oxygen via a face mask at 7 to 10 liters per minute. Answer: 4 Note the strategic word, first. This question requires you to identify the first nursing action that you will take. Also use the ABCs—airway, breathing, and circulation—to answer correctly. Administering oxygen will increase the amount of oxygen for transport to the fetus, partially compensating for the loss of circulating blood volume. This action is essential regardless of the cause or amount of bleeding. IV fluids will also be initiated. Although a cesarean delivery may be needed, there are no data that indicate it is necessary at this time. The client will be positioned based on the cause of fetal distress and per primary health care provider’s prescription. Level of Cognitive Ability: Applying The NGN item types use a case study approach as stand-alone cases and unfolding case studies. The stand-alone cases will be accompanied by a question that tests more than one cognitive skill. The unfolding case studies will be accompanied by six NGN item type questions, and each cognitive skill will be tested. Examples of NGN items can be located on the Evolve site accompanying this book. These are specially designed to simulate the NCLEX experience of testing for these NGN item types. Chapter 4, Box 4.26, provides an example of a Bowtie NGN question. Table 1.4 provides a list of the NGN question types. The NCSBN also identifies three scoring methods for NGN items. These scoring methods are described in Table 1.5. The NCSBN provides specific directions for you to follow with all question types to guide you through the testing process. Be sure to read these directions as they appear on the computer screen. Examples of some of these types of questions are noted in this chapter. Most question types are also placed in this book, and all types, including the NGN items, are 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 provide you with data about a client situation and four 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 calculation. The rules for rounding an answer are described in the tutorial provided by the NCSBN and are also provided in the specific question on the computer screen. In addition, you must type a decimal point if necessary and noted in the question directions. See Box 1.2 for an example of a fill-in-the-blank question. 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 this question type, there will be five to ten possible options, and there may be one or more correct answers. Partial credit is given for correct selections. See Box 1.3 for an example. Ordered Response (Prioritizing) Questions In ordered response (prioritizing) questions you will be asked to place 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. Specific directions for answering are provided with the question. See Fig. 1.1 for an example. Examples of this question type are located on the accompanying Evolve site. Figure Questions A question with a picture or graphic will ask you to answer the question based on the picture or graphic. The question could contain a chart, a table, or a figure or illustration. You also may be asked to use the computer mouse to point and click on a specific area in the visual. A figure or illustration may appear in any type of question, including a multiple choice question. See Box 1.4 for an example. TABLE 1.4 NGN Item Types Type of Case Description Item Types Scenario Stand- A stand-alone case will include a Bowtie alone short scenario about a client Trend and will be accompanied by one question that tests more than one cognitive skill. Type of Case Description Item Types Scenario Unfolding An unfolding case study will Highlight in include phases as the story Text about the client unfolds and Highlight in changes. This will be Table accompanied by six NGN item Matrix type questions, and each of the Multiple six cognitive skills will be Choice tested. Matrix Multiple Response Multiple Response Select N Multiple Response Select All That Apply Multiple Response Grouping Drag and Drop Cloze Drag and Drop Rationale Drop Down Cloze Drop Down Rationale Drop Down in Table From: Petersen, E., Betts, J., & Muntean, W. (December 2020). Next Generation NCLEX® (NGN) Webinar. NCSBN; National Council of State Boards of Nursing. (2021). Next Generation NCLEX News. https://www.ncsbn.org/NGN_Summer21_Eng.pdf TABLE 1.5 NGN Scoring Methods Method Description Plus-Minus One point is given for each correct response (+/−) One point is subtracted for each incorrect Scoring response If the sum is negative, a zero is assigned Used when the test-taker can select any number of options such as a multiple response, select all that apply, matrix multiple response, highlight in text, highlight in table, multiple response grouping One-Zero One point is given for each correct response (1/0) Points are NOT subtracted for incorrect Scoring responses Used for items such as Bowtie, matrix multiple choice, Select N, drop down cloze, drag and drop cloze, or drop down table Rationale One point is given for each correct grouping of Scoring response elements Used when elements of a response are linked such as drop down rationale or drag and drop rationale items From: National Council of State Boards of Nursing. (2021). Next Generation NCLEX News. https://www.ncsbn.org/NGN_Summer21_Eng.pdf; National Council of State Boards of Nursing. (2021). Braving new pathways: Leading the way for regulatory transformation, 2021 NCSBN Annual Meeting. Scenario/Exhibit Questions In this type of question, you will be presented with a problem and a scenario or exhibit. You will be provided with three or more 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 1.5 for an example. BOX 1. 2 F il l - in- th e -Blank Qu e s tion The physician prescribes 12 mEq of liquid potassium chloride. The medication label reads 20 mEq/15 mL. The nurse needs to administer how many milliliters (mL) to the client? Answer: 9 mL Focus on the subject, the amount of mL to be administered, and on the data in the question. For this fill-in-the-blank question, use the formula for calculating medication doses. Once 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 when answering a question. Also, remember that there will be an on-screen calculator on the computer for your use to confirm your answer. Formula: Graphic Option Questions In graphic option questions the option selections will be pictures rather than text. You will select the option that represents your answer choice. See Box 1.6 for an example. Audio Questions Audio questions will require listening to a sound to answer 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 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). BOX 1. 3 Mu l t ip le R e s p ons e Qu e s tion The nurse is caring for a client with a terminal condition who is dying. Which respiratory assessment findings would indicate to the nurse that death is imminent? Select all that apply. 1. Dyspnea 2. Cyanosis 3. Kussmaul’s respiration 4. Tachypnea without apnea 5. Irregular respiratory pattern 6. Adventitious bubbling lung sounds Answer: 1, 2, 5, 6 Focus on the subject, assessment findings in a client who is dying. In a multiple response question, you will be asked to select or check all the options, such as signs and symptoms or interventions that relate to the information in the question. Be sure to follow the specific directions given on the computer screen. Partial credit is given for multiple response questions. To answer this question, think about the respiratory assessment findings that indicate death is imminent. These include altered patterns of respiration, such as slow, labored, irregular, or Cheyne-Stokes pattern (alternating periods of apnea and deep, rapid breathing); increased respiratory secretions and adventitious bubbling lung sounds (death rattle); irritation of the tracheobronchial airway as evidenced by hiccups, chest pain, respiratory fatigue, or exhaustion; and poor gas exchange as evidenced by hypoxia, dyspnea, or cyanosis. Kussmaul’s respirations are abnormally deep, very rapid sighing respirations characteristic of diabetic ketoacidosis. Case Study Questions Case study questions are the format for the NGN-style items. These case studies may be stand-alone or unfolding cases. The stand-alone case studies will be accompanied by one NGN-style question, and the unfolding case studies will be accompanied by six questions in NGN style. Each type of case study is aimed at testing one or more of the cognitive skills or processes associated with the NCSBN Clinical Judgment Measurement Model (see Table 1.1). Examples of these NGN item types can be located on the Evolve site accompanying this book. Registering to Take the Examination It is important to obtain an NCLEX® Examination Candidate Bulletin from the NCSBN website at https://www.ncsbn.org, because this bulletin provides all of the information you need to register for and schedule your examination. It also provides you with website and telephone information for NCLEX examination 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 NCLEX® Examination Candidate Bulletin as your guide to complete the registration process. Following the registration instructions and completing the registration forms precisely and accurately are important. Registration forms not properly completed 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. FIGURE 1.1 Example of an ordered response question. BOX 1. 4 F igu re Qu e s tio n The nurse performs client rounds and notes that a client with a respiratory disorder is wearing this oxygen device (refer to figure). The nurse would document that the client is receiving oxygen by which type of low-flow oxygen delivery system? Refer to figure.  Figure from Potter, P., Perry, A., Stockert, P. & Hall, A.. Fundamentals of nursing. [9th ed.] Mosby. 1. Venturi mask 2. Nasal cannula 3. Simple face mask 4. Partial rebreather mask Answer: 3 Focus on the subject, the type of face mask that the client is wearing. For some of these question types, you need to use the computer mouse and point and click at a designated area to answer the question. For this question, use of the computer mouse is not necessary. A simple face mask is used to deliver low-flow oxygen concentrations of 40% to 60% for short-term oxygen therapy. It also may be used in an emergency. A minimum flow rate of 5 L/min is needed to prevent the rebreathing of exhaled air. The simple face mask fits over the nose and mouth, has exhalation ports, and has a tube that connects to the oxygen source. A Venturi mask is a high-flow oxygen delivery system that delivers an accurate oxygen concentration. An adaptor is located between the bottom of the mask and the oxygen source. The adaptor contains holes of different sizes that allow specific amounts of air to mix with the oxygen. The nasal cannula contains nasal prongs that are used to deliver oxygen flow rates at 1 to 6 L/min. A partial rebreather mask is a mask with a reservoir bag without flaps. It provides oxygen concentrations of 60% to 75% with flow rates of 6 to 11 L/min. BOX 1. 5 Sc e nario /Exhib it Qu e s tion Oral prednisone is prescribed for a hospitalized client. The nurse reviews the client’s medical record and is most concerned about this prescription because of which documented item? Refer to chart. 1. Furosemide 2. Hypertension  3. Diabetes mellitus 4. Normal electrocardiogram Answer: 3 Note the strategic word, most. This scenario/exhibit question provides you with data from a client’s medical chart, identifies a prescribed medication, and asks about a concern related to this medication. Read all the data in the question and the client’s chart. Use nursing knowledge about the interactions and effects of prednisone, and recall that this medication may increase the blood glucose level. This will assist in directing you to option 3. For these question types, be certain to read all of the data in the client’s chart before selecting the answer. Remember you will be provided with tabs to click to read information. Authorization to Test Form and Scheduling an Appointment Once you are eligible to test, you will receive an Authorization 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 provides you with the directions for scheduling an appointment, 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 (ID) 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 examination if you do not have this form. Changing Your Appointment If for any reason you need to change your appointment to test, you can make the change on the candidate website or by calling candidate services. Refer to the NCLEX® Examination Candidate Bulletin for this contact information and other important procedures for canceling and changing an appointment. If you fail to arrive for the examination or fail to cancel your appointment to test without providing appropriate notice, you will forfeit your examination fee, and your ATT form will be invalidated. This information 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. BOX 1. 6 Gr ap hic Op tio ns Qu e s t ion The primary health care provider prescribes a tuberculin skin test to be done on a client. Which syringe would the nurse select to perform the test? Refer to Figures 1 to 4. Answer: 2 Focus on the subject, the procedure for administering a tuberculin skin test. This question requires you to select the picture that represents your answer choice. To perform a tuberculin skin test, the nurse would use a tuberculin syringe that is marked in 0.01 (hundredths) because the dose for administration is less than 1 mL. Option 1 is a 3-mL syringe and is marked in 0.1 (tenths) and is used for most subcutaneous or intramuscular injections. Insulin syringes are available in 50 and 100 units and are used to administer insulin. (Figure from Potter, P., Perry, A., Stockert, P., & Hall, A.. Fundamentals of nursing. [9th ed.]. Mosby.) The 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 destination; 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 such as a U.S. driver’s license, passport, U.S. state ID, or U.S. military ID to be admitted to take the examination. All acceptable ID 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 ATT form. 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 contact the board of nursing before submitting a registration form. The board of nursing will provide the procedures for the request. The board of nursing must authorize testing accommodations. After 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. A digital signature and photograph will also be taken at the testing center. These identity confirmations will accompany the NCLEX exam results. In addition, if you leave the testing room for any reason, you may be required to perform these identity confirmation 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 bag provided by the test administrator and kept in a locker. Any evidence of tampering with the bag could result in the need to report the incident and test cancellation. A locker and locker key will be provided for you; however, storage space is limited, so you must plan accordingly. In addition, the testing center will not assume responsibility for your personal belongings. The testing waiting areas are generally small; friends or family members who accompany 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 computer. 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, and the use of tobacco are not allowed in the testing room. You will be observed at all times by the test administrator while taking the examination. In addition, video and audio recordings of all test sessions are made. The testing center has no control over the sounds made by typing on the computer by others. If these sounds are distracting, raise your hand to summon the test administrator. Earplugs are available on request. You must follow the directions given by the testing center 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 reason, you must raise your hand. You are also encouraged to access the NCSBN candidate website to obtain additional information about acceptable medical devices that can be brought into the testing room and the physical environment of the testing center; you can also view a virtual tour of the testing center. FIGURE 1.2 Example of an audio question. TABLE 1.6 NGN Test Design NGN Minimum NGN Maximum Element Length Exam Length Exam Scored Items 85 (70 scored and 15 150 (135 scored and 15 unscored) unscored) Unfolding 3 cases (total of 18 3 cases (total of 18 case items) items) studies Stand-alone Possibly Bowtie or Possibly Bowtie or items Trend Trend Traditional Approximately 52 Approximately 52-117 item types (dependent on # (dependent on # of of stand-alones) stand-alones) Pretest 15 15 (Unscored) Items Time Allowed 5 hours 5 hours Adapted from: National Council of State Boards of Nursing. (2021). Braving new pathways: Leading the way for regulatory transformation, 2021 NCSBN Annual Meeting. NGN Test Design The time allowed for the exam is 5 hours; this period includes the tutorial, the sample items, all breaks, and the examination. All breaks are optional. Remember that all breaks count against testing time. If you take a break, you must leave the testing room; when you return, you may be required to follow identity confirmation procedures to be readmitted. Pretest items will be a part of the examination. The pretest questions are questions that may be presented 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. Table 1.6 provides information about the test design. 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. Additional information about pass-or-fail decisions can be found in the NCLEX® Examination Candidate Bulletin located at https://www.ncsbn.org. Completing the Examination When the examination has ended, you will complete a brief computer-delivered questionnaire about your testing experience. After you complete this questionnaire, 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 6 weeks 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 NCLEX result by this method can be obtained on the NCSBN website by clicking candidate services. Candidate Performance Report A candidate performance report is provided to a test-taker who failed the examination. This report provides the test-taker with information about strengths and weaknesses in relation to the test plan framework and provides a guide for studying and retaking the examination. If a retake is necessary, the candidate must wait 45 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 procedures regarding when the examination can be taken again. Interstate Endorsement and Nurse Licensure Compact Because the NCLEX-RN examination is a national examination, you can apply to take the examination in any state. When licensure is received, you can apply for interstate endorsement, which is obtaining another license in another state to practice nursing in that state. The procedures 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. 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 website at https://www.ncsbn.org. The International-Educated Nurse An important first step in the process of obtaining information about becoming a registered nurse in the United States is to access the NCSBN website at https://www.ncsbn.org and obtain information provided for international-educated nurses in the NCLEX website link. The NCSBN provides information about some of the documents you need to obtain as an international-educated nurse seeking licensure in the United States and about credentialing agencies. Refer to Box 1.7 for a list of some of these 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 website 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 credentialing 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 RN licensure. You should also ask about the specific documents needed to become eligible to take the NCLEX exam. You can obtain contact information for each state board of nursing through the NCSBN website at https://www.ncsbn.org. 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 1-866-293-9600; international telephone is 011-1-312-525-3600; the fax number is 1-312-279-1032. BOX 1. 7 I nt e r national-Ed u cate d Nu r s e : So m e D oc u m e nts Ne e de d to Ob tain Lice ns u r e 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. Official transcripts of educational credentials sent directly to credentialing agency or board of nursing from home country  school of nursing 7. Validation of a comparable nursing education as that provided in U.S. nursing programs; this may include theoretical instruction and clinical practice in a variety of nursing areas including, but not limited to, medical nursing, surgical nursing, pediatric nursing, maternity and newborn nursing, community and public health nursing, and mental health nursing 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 Chapter 2: Self-Efficacy and Profiles to Success Laurent W. Valliere The Pyramid to Success Preparing to take the National Council Licensure Examination Next Generation NCLEX® (NGN) can produce a great deal of anxiety in the nursing graduate. You may be thinking that the NCLEX-RN is the most important examination that you will ever have to take and that it reflects the culmination of everything for which you have worked so hard. The NGN is an important examination because achieving that nursing license defines the beginning of your career as a registered nurse. A vital ingredient to your success on the NCLEX is examining your profile to success and avoiding negative thoughts that allow this examination to seem overwhelming and intimidating (Box 2.1). Such thoughts will take full control over your destiny. A strong positive attitude and self-efficacy, a structured plan for preparation, and maintaining control in your pathway to success ensure reaching the peak of the Pyramid to Success (Fig. 2.1). For additional information about study habits and testing and test anxiety, we refer you to Saunders 2024-2025 Clinical Judgment and Test-Taking Strategies resource. Self-Efficacy The concept of self-efficacy was originally proposed by Albert Bandura in social science research in developing social cognitive theory. According to Bandura (1977), this theory has been used extensively in the field of psychology. Central to Bandura’s work are the concepts of self-efficacy and self-efficacy (outcome) expectations. The concept of self-efficacy is described as a type of self-reflection that affects one’s behavior (Bandura, 1977). Self-reflection enables an individual to assess their own experiences, develop perceptions about their own capabilities that guide behavior, and determine how much effort will ensure performance. Thus, self-reflection leads to an individual’s self-efficacy expectations and confidence in their ability to succeed. BOX 2. 1 Pro fil e s to Su cce s s □ Avoid negative thoughts that allow the examination to seem overwhelming and intimidating. □ Develop a comprehensive plan to prepare for the examination. □ Examine the study methods and strategies that you used in preparing for examinations during nursing school. □ Develop realistic time goals. □ Select a study time period and study place that will be most conducive to your success. □ Commit to your own special study methods and strategies. □ Incorporate a balance of exercise with adequate rest and relaxation time in your preparation schedule. □ Maintain healthy eating habits. □ Learn to control anxiety. □ Remember that discipline and perseverance will automatically bring control. □ Remember that this examination is all about you. □ Remember that your self-confidence and the belief in yourself will lead you to success! With regard to NCLEX, a study done by Silvestri, Clark, & Moonie (2013) showed that self-efficacy expectations were an important predictor for NCLEX success. Self-Efficacy Expectations Self-efficacy expectations are focused on one’s belief in their own capacity to carry out particular behaviors. These expectations determine the behaviors a person chooses to perform, their degree of perseverance, and the quality of the performance. Bandura (1997) describes self-efficacy as an individual’s belief regarding their own abilities to successfully perform activities or tasks and indicates that the stronger the sense of self-efficacy, the more confident one is to succeed. In applying Bandura’s (1977) theory to NCLEX success, if you have high self-efficacy expectations, you will work hard and persevere and believe that you will achieve NCLEX success. Conversely, if your self-efficacy expectations are low, this could lead to self-doubt about your ability to achieve success on NCLEX. FIGURE 2.1 The Pyramid to Success. Profiles to Success: Increasing Self- Efficacy Self-Reflection Self-reflection enables an individual to assess their own experiences, develop perceptions about their own capabilities that guide behavior, and determine how much effort will ensue for performance. Thus, self-reflection leads to an individual’s self-efficacy expectations and confidence in their ability to succeed. According to Bandura (1997), individuals possess a self-regulatory function that provides the capability to influence their own cognitive processes and actions and thus alter their environments. Therefore, whatever self-efficacy beliefs an individual holds will help to determine what activities the individual will pursue, the effort that they will expend in pursuing these activities, and how long they will persist in the face of obstacles and hardships. To start, take some time to self-reflect. Think about the accomplishments you have achieved and how you have achieved these accomplishments. Journal these accomplishments and keep these in mind. Review them whenever you begin to feel any self- doubt about your ability to succeed on the NCLEX. Some self- reflection questions to ask yourself include the following: 1. Am I a goal-setter? 2. Do I develop a plan and determine what activities I need to pursue to achieve my goals? 3. Do I set goals that are unrealistic to achieve in a specific time frame? 4. Do I accomplish the goals that I set? 5. How much time and effort do I put in to accomplish my goals? 6. Do I find ways to achieve my goals when I am faced with life challenges and obstacles? 7. How do I feel when I accomplish a goal? Developing Your Preparation Plan The foundation begins with a strong positive attitude and self- efficacy, the belief that you will achieve success, and developing self- control. Nursing graduates preparing for the NCLEX must develop a comprehensive plan to prepare for this examination. The most important component in developing a plan is identifying the study patterns that guided you to your nursing degree. It is important to begin your planning by reflecting on all of the personal and academic challenges you experienced during your nursing education. Take time to focus on the thoughts, feelings, and emotions that you experienced before taking an examination while enrolled in your nursing program. Examine the methods that you used in preparing for that examination both academically and from the standpoint of how you dealt with the anxiety that parallels the experience of facing an examination. These factors are very important considerations in preparing for the NCLEX because they identify the patterns that worked for you. Think about this for a moment. Your own methods of study must have worked, or you would not be at the point of preparing for the NCLEX-RN. Each individual requires their own methods of preparing for an examination. Graduate nurses who have taken the NCLEX-RN will probably share their experiences and methods of preparing for this challenge with you. It is very helpful to listen to what they tell you. These graduates can provide you with important strategies that they have used. Listen closely to what they have to say, but remember that this examination is all about you. Your identity and what you require in terms of preparation are most important. Reflect on the methods and strategies that worked for you throughout your nursing program. Do not think that you need to develop new methods and strategies to prepare for the NCLEX. Use what has worked for you. Take some time to reflect on these strategies, write them down on a large blank card, sign your name, and write “RN” after your name. Post this card in a place where you will see it every morning. Commit to your own special strategies. These strategies reflect your profile and identity and will lead you to a successful outcome—registered nurse! A frequent concern of graduates preparing for the NCLEX relates to deciding whether they should study alone or become a part of a study group. Examining your profile will easily direct you in making this decision. Again, reflect on what has worked for you throughout your nursing program as you prepared for examinations. Remember, your needs are most important. Address your own needs, and do not become pressured by peers who are encouraging you to join a study group if this is not your normal pattern for study. Additional pressure is not what you need at this important time of your life.  You may ask, “What is the best method of preparing?” First, remember that you are prepared. In fact, you began preparing for this examination on the first day that you entered your nursing program. The task you are faced with is to review, in a comprehensive manner, all of the nursing content that you learned in your nursing program. It can become totally overwhelming to look at your bookshelf, which is overflowing with the nursing books you used during nursing school, and your challenge becomes monumental when you look at the boxes of nursing lecture notes that you have accumulated. It is unrealistic to even think that you could read all of those nursing books and lecture notes in preparation for the NCLEX. These books and lecture notes should be used as reference sources, if needed, during your preparation for the NCLEX. Saunders Comprehensive Review for the NCLEX-RN® Examination has identified for you all of the important nursing content areas relevant to the examination. During the comprehensive review, you should have noted the areas that are unfamiliar or unclear to you. Be sure that you have taken the time to become familiar with these areas. Now, you are progressing through the Pyramid to Success and testing your knowledge in this book, Saunders Q&A Review for the NCLEX-RN® Examination. Answer all of the practice questions provided in this book and on the Evolve site: practice question, after question, after question! You may identify nursing content areas that require further review. Take the time to review these nursing content areas, as you are guided to do in this book. Identifying Your Goals for Success Create a list of your goals related to NCLEX preparation. Open your calendar and start with listing your daily goals and what you want to accomplish each day. Your daily goal could be practicing a specific number of questions or reviewing a specific content area, or it could be a day of rest and relaxation! Your profile to success requires that you develop realistic time goals to prepare for the NCLEX. It is necessary to take the time to examine your life and all of the commitments you may have. These commitments may include family, work, and friends. As you develop your goals, remember to plan time for fun and exercise. To achieve success, you require a balance of time for both work and enjoyment. If you do not plan for some leisure time, you will become frustrated and perhaps even angry. These sorts of feelings will block your ability to focus and concentrate. Remember that you need time for yourself. Goal development may be a relatively easy process because you have probably been juggling your life commitments ever since you entered nursing school. Remember that your goal is to identify a daily time frame and time period for you to use in reviewing and preparing for the NCLEX. Open your calendar and identify days on which life commitments will not allow you to spend this time preparing. Block those days off and do not consider them as a part of your review time. Identify the time of day that is best for you in terms of your ability to concentrate and focus so that you can accomplish the most in your identified time frame. Be sure that you consider a time that is quiet and free of distractions. Many individuals find the morning hours most productive, whereas others may find the afternoon and evening hours most productive. Remember that this examination is all about you, so select the time period that will be most conducive to your success. Selecting Your Study Place The place of study is very important. Select a place that is quiet and comfortable for study—where you normally do your studying and preparing. If studying at home in your own environment is your normal pattern, be sure to free yourself of distractions during your scheduled preparation time. If you are not able to free yourself of distractions, you may consider spending your preparation time in a library. When selecting your place of study, reflect on what worked best for you during your nursing program. Deciding on Your Amount of Daily Study Time Selecting the amount of daily preparation time can be troublesome for many graduates preparing for the NCLEX. It is very important to set a realistic time period that can be adhered to on a daily basis. Set a time frame that will provide you with quality time and a time frame that can be achieved. If you set a time frame that is not realistic and cannot be achieved every day, you will become frustrated. This frustration will block your journey toward the peak of the Pyramid to Success. The best suggestion is to spend at least 2 hours daily for NCLEX preparation. Two hours is a realistic time period, both in terms of spending quality time and adhering to a time frame. You may find that after 2 hours your ability to focus and concentrate is diminished. You may, however, find that on some days you are able to spend more than the scheduled 2 hours. If you can and feel as though your ability to concentrate and focus is still present, then do so. Developing Control Discipline and perseverance will automatically bring control. Control will provide you with the momentum that will sweep you to the peak of the Pyramid