Saunders Comprehensive Review for the NCLEX-RN Examination PDF

SAUNDERS COMPREHENSIVE REVIEW 2 for the 3 NCLEX-RN® 4 EXAMINATION Linda Anne Silvestri, PhD, RN Instructor of Nursing Salve Regina University, Newport, Rhode Island President Nursing Reviews,...

SAUNDERS COMPREHENSIVE REVIEW 2 for the 3 NCLEX-RN® 4 EXAMINATION Linda Anne Silvestri, PhD, RN Instructor of Nursing Salve Regina University, Newport, Rhode Island President Nursing Reviews, Inc. and Professional Nursing Seminars, Inc., Charlestown, Rhode Island Nursing Reviews, Inc., Las Vegas, Nevada Instructor NCLEX-RN® and NCLEX-PN® Review Courses 5  3251 Riverport Lane St. Louis, Missouri 63043 SAUNDERS COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION ISBN: 978-1-4557-2755-1 Copyright © 2014, 2012, 2009 by Saunders, an imprint of 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 and 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). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods, they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their 6  patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability 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. NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc. Library of Congress Cataloging-in-Publication Data Silvestri, Linda Anne, author. Saunders comprehensive review for the NCLEX-RN examination / Linda Anne Silvestri. – Edition 6. p. ; cm. Comprehensive review for the NCLEX-RN examination Includes bibliographical references and index. ISBN 978-1-4557-2755-1 (pbk. : alk. paper) I. Title. II. Title: Comprehensive review for the NCLEX-RN examination. [DNLM: 1. Nursing, Practical–Examination Questions. 2. Nursing Care–Examination Questions. 3. Nursing Process–Examination Questions. WY 18.2] RT55 2013019281 610.73'076–dc23 Executive Content Strategist: Kristin Geen Associate Content Development Specialist: Laura Goodrich Content Coordinator: Hannah Corrier Publishing Services Manager: Jeff Patterson Senior Project Manager: Clay S. Broeker Design Direction: Brian Salisbury Multimedia Producer: Lisa Godoski 7  To my parents— To my mother, Frances Mary, and in loving memory of my father, Arnold Lawrence, who taught me to always love, care, and be the best that I could be. 8 To All Future Registered Nurses, Congratulations to you! You should be very proud and pleased with yourself on your most recent well- deserved accomplishment of completing your nursing program to become a registered nurse. I know that you have worked very hard to become successful and that you have proven to yourself that indeed you can achieve your goals. In my opinion, you are about to enter the most wonderful and rewarding profession that exists. Your willingness, desire, and ability to assist those who need nursing care will bring great satisfaction to your life. In the profession of nursing, your learning will be a lifelong process. This aspect of the profession makes it stimulating and dynamic. Your learning process will continue to expand and grow as the profession continues to evolve. Your next very important endeavor will be the learning process involved to achieve success in your examination to become a registered nurse. I am 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. I want to thank all of my former nursing students whom I have assisted in their studies for the NCLEX-RN exam for their willingness to offer ideas regarding their needs in preparing for licensure. Student ideas have certainly added a special uniqueness to all of the products available in the Saunders 9 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 10 About the Author Linda Anne Silvestri, PhD, RN (Photo by Laurent W. Valliere.) As a child, I always dreamed of becoming either a nurse or a teacher. Initially I chose to become a nurse because I really wanted to help others, especially those who were ill. Then I realized that both of my dreams could come true; I could be both a nurse and a teacher. So I pursued my dreams. I received my diploma in nursing at Cooley Dickinson Hospital School of Nursing in Northampton, Massachusetts. Afterward, I worked at Baystate Medical Center in Springfield, Massachusetts, where I cared for clients in acute medical-surgical units, the intensive care unit, the emergency department, pediatric units, and other acute care units. 11 Later I received an associate degree from Holyoke Community College in Holyoke, Massachusetts; my BSN from American International College in Springfield, Massachusetts; and my MSN from Anna Maria College in Paxton, Massachusetts, with a dual major in Nursing Management and Patient Education. I received my PhD in Nursing from the University of Nevada, Las Vegas (UNLV), and conducted research on self-efficacy and the predictors of NCLEX success. In 2012, I received the UNLV School of Nursing, Alumna of the Year Award. I am also a member of the Honor Society of Nursing, Sigma Theta Tau International, Phi Kappa Phi, the Western Institute of Nursing, the Eastern Nursing Research Society, the Golden Key International Honour Society, the National League for Nursing, and the American Nurses Association. As a native of Springfield, Massachusetts, I began my teaching career as an instructor of medical-surgical nursing and leadership-management nursing in 1981 at Baystate Medical Center School of Nursing. In 1989, I relocated to Rhode Island and began teaching advanced medical-surgical nursing and psychiatric nursing to RN and LPN students at the Community College of Rhode Island. While teaching there, a group of students approached me for assistance in preparing for the NCLEX examination. I have always had a very special interest in test success for nursing students because of my own personal experiences with testing. Taking tests was never easy for me, and as a student I needed to find methods and strategies that would bring success. My own difficult experiences, desire, and dedication to assist nursing students to overcome the obstacles associated with testing inspired me to develop and write the many products that would foster success with testing. My experiences as a student, nursing educator, and item writer for the NCLEX exams aided me as I developed a comprehensive review course to prepare nursing graduates for the NCLEX examination. Later, in 1994, I began teaching medical-surgical nursing at Salve Regina University in 12 Newport, Rhode Island, and I remain there as an adjunct faculty member. I also prepare nursing students at Salve Regina University for the NCLEX-RN examination. I established Professional Nursing Seminars, Inc. in 1991 and Nursing Reviews, Inc. in 2000. These companies are located in Charlestown, Rhode Island. In 2012, I established an additional company, Nursing Reviews, Inc. in Las Vegas, Nevada. Both companies are dedicated to conducting review courses for the NCLEX-RN and the NCLEX-PN examinations and helping nursing graduates achieve their goals of becoming registered nurses, licensed practical/vocational nurses, or both. Today, I am the successful author of numerous review products. Also, I serve as an Elsevier consultant for HESI Live Reviews, the review courses for the NCLEX examinations throughout the country. I am so pleased that you have decided to join me on your journey to success in testing for nursing examinations and for the NCLEX-RN examination! 13 Contributors Consultants Allison E. Bowser, MA Researcher and Proofreader Leesburg, Georgia Dianne E. Fiorentino Research Coordinator Nursing Reviews, Inc. Charlestown, Rhode Island James Guibault Jr., BS, PharmD Candidate Massachusetts College of Pharmacy and Health Sciences Worcester, Massachusetts Holyoke Medical Center, Pharmacy Intern Holyoke, Massachusetts Nicholas L. Silvestri, BA Editorial and Communications Analyst 14 Nursing Reviews, Inc. Charlestown, Rhode Island Special Contributor Eileen Gray, DNP, RN, CPNP Chair, Department of Nursing Salve Regina University Newport, Rhode Island Contributors Marilee Aufdenkamp, RN, MS Assistant Professor Creighton University School of Nursing Hastings, Nebraska Margaret Barnes, MSN, RN Assistant Professor Indiana Wesleyan University Marion, Indiana Reitha Cabaniss, MSN, RN, CNE Nursing Director Bevill State Community College Jasper, Alabama Joanna E. Cain, BSN, BA, RN President and Founder Auctorial Pursuits, Inc. Austin, Texas 15 Barbara Callahan, MEd, RN, NCC, CHSE Nursing Faculty Lenoir Community College Kinston, North Carolina Mary C. Carrico, MS, RN Associate Professor of Nursing West Kentucky Community and Technical College Paducah, Kentucky Mary L. Dowell, PhD, RN, BC Assistant Professor San Antonio College San Antonio, Texas Beth B. Gaul, PhD, RN Professor of Nursing Grand View University Des Moines, Iowa Susan Golden, MSN, RN Interim Dean of Health ENMU-Roswell Roswell, New Mexico Marilyn L. Johnessee Greer, MS, RN Associate Professor of Nursing Rockford College Rockford, Illinois 16 Jamie Lynn Jones, MSN, RN, CNE Assistant Professor University of Arkansas at Little Rock Little Rock, Arkansas Lynn Korvick, PhD, RN, CNE Chair of Nursing Missouri Southern State University Joplin, Missouri Tara McMillan-Queen, RN, MSN, ANP, GNP Faculty II Mercy School of Nursing Charlotte, North Carolina Heidi Monroe, MSN, RN-BC, CPAN, CAPA Assistant Professor of Nursing Bellin College Green Bay, Wisconsin David Morrow, BSN, RN Graduate, University of Nevada, Las Vegas Las Vegas, Nevada Debra L. Price, RN, MSN, CPNP Assistant Professor of Nursing Tarrant County College Fort Worth, Texas Donna Russo, RN, MSN, CCRN 17 Nursing Instructor Frankford Hospital School of Nursing Philadelphia, Pennsylvania Angela E. Silvestri, RN, MSN PhD Student and Graduate Assistant School of Nursing, University of Nevada Las Vegas, Nevada Christine Sump, MSN, RN Lecturer School of Nursing Old Dominion University Norfolk, Virginia Bethany Hawes Sykes, EdD, RN, CEN, CCRN Adjunct Faculty Department of Nursing Salve Regina University Newport, Rhode Island Linda Turchin, RN, MSN, CNE Assistant Professor of Nursing Fairmont State University Fairmont, West Virginia Laurent W. Valliere, BS, DD Vice President of Nursing Reviews, Inc. Professional Nursing Seminars, Inc. 18 Charlestown, Rhode Island The author and publisher would also like to acknowledge the following individuals for contributions to the previous editions of this book: JoAnn Acierno, BSN, RN Omaha, Nebraska Marion G. Anema, PhD, RN Nashville, Tennessee Marianne P. Barba, MS, RN, CPC Coventry, Rhode Island Carol A. Baxter, EdD, RN Lancaster, Pennsylvania Eloise M. Brotzman, MSEd, MSN, RNC Bethlehem, Pennsylvania Janice Almon Call, MSN, RN, C Gainesville, Texas Darlene Nebel Cantu, MSN, RNC San Antonio, Texas Heather Carlson, RN Newport, Rhode Island Elizabeth M. Carson, EdD, RN Rockford, Illinois Shannon Chase, RN Newport, Rhode Island Jane Anne Claffy, MSN, RNC 19 Germantown, New York Alice D. Coomes, MSN, RN Owensboro, Kentucky Barbara Cornett, PhD, CNS, RN, CHES Westerville, Ohio Gloria Coschigano, MSN, RN, CS Valhalla, New York Nancy Wilson Darland, MSN, RNC, CNS Ruston, Louisiana Jean W. Davis, EdD, RN, CS Miami Shores, Florida Jean DeCoffe, MSN, RN Milton, Massachusetts Carole A. Devine, MSN, RN Newport, Rhode Island Katherine H. Dimmock, JD, EdD, MSN, RN Milwaukee, Wisconsin Julie Eggert, PhD, GNP-C, AOCN Clemson, South Carolina Kerry H. Fater, PhD, RN, CS North Dartmouth, Massachusetts Ginette G. Ferszt, PhD, RN, CS Kingston, Rhode Island Katherine A. Fletcher, PhD, RN, CS 20 Kansas City, Kansas Cathy Fortenbaugh, MSN, RN, AOCN, CNS-C Philadelphia, Pennsylvania Jane H. Freeman, EdD, RN Jacksonville, Alabama Cynthia A. Gaudet, MSN, RN Springfield, Massachusetts Rita S. Glazebrook, PhD, RN, CNP Northfield, Minnesota Kimberly Green, RN Newport, Rhode Island Karen Clark Griffith, PhD, RN Iowa City, Iowa Joyce Hammer, MSN, RN Detroit, Michigan Jacqueline Lynne Harris, MNSc, RN, ONC Searcy, Arkansas Amy Zlomek Hedden, RN, MS, NP Bakersfield, California Beverly K. Hogan, APRN, BC Birmingham, Alabama Mary Ann Hogan, MSN, RN, CS Amherst, Massachusetts Mary Kathleen Jackson, BSN, RN, CPN 21 Whiteville, North Carolina Gail M. Johnson, EdD, MSN, RN, CNAA, BC Trenton, New Jersey Juanita F. Johnson, PhD, RN Shawnee, Oklahoma Katherine Theresa Jorgensen, MSN, RN, MA Vermillion, South Dakota Katje A. Koning, RN Storrs, Connecticut Elisa Mangosing Lemmon, MSN, RN-C Newport News, Virginia Teresa Leonard, MSN, RN, CCRN Florence, Alabama Carol O. Long, PhD, RN Tempe, Arizona Marilyn Lusk, MSN, MS, RN Kingman, Arizona Lois S. Marshall, PhD, RN Miami, Florida Linda Ann Martin, MSN, RN, APN-C Trenton, New Jersey Dorothy Mae Mathers, MSN, RN Williamsport, Pennsylvania Ellyn E. Matthews, PhD, RN, AOCN, CRNI 22 Denver, Colorado Ellen C. McElroy, DSN, RN Birmingham, Alabama Susan A. Moore, PhD, RN Memphis, TN Jo Ann Barnes Mullaney, PhD, RN, CS Newport, Rhode Island Betsy J. Nield, MS, RNC Warwick, Rhode Island Tina Nink, MSN, RN, FNP Oglesby, Illinois Lolita T. O’Donnell, PhD, MSN, RN Fairfax, Virginia Kathleen A. Ohman, EdD, MS, RN, CCRN St. Cloud, Minnesota Patricia A. Parsons, MSN, MS, RN Austin, Minnesota Elizabeth Phillip, MSN, RN Bethlehem, Pennsylvania Tommie Wright Pniewski, MSN, RN, CNAA Hopkinsville, Kentucky Emily Porterfield, RN, LDN Greenville, North Carolina Ethel Pruden, MSN, RN 23 Savannah, Georgia Marion Sawyier, MSN, RN Albuquerque, New Mexico Nancy Schlapman, PhD, RN Kokomo, Indiana Jane Schlickau, MN, RN, ARNP, CTN Winfield, Kansas Joan Schmitke, DSN, APRN, FNP, BC Richmond, Kentucky Bruce Austin Scott, MSN, APRN, BC Stockton, California Geneva Scott, MSN, RN, BSS Weatherford, Texas Shirley Sherrick-Escamilla, PhD(c), MSN, RNC Detroit, Michigan Shellie Simons, MS, RN Boston, Massachusetts Mary M. Smith, MSN, RN Charlotte, North Carolina Fran Soukup, RN, MSN, EdS Albany, New York Marian I. Stewart, MSN, RN Lynchburg, Tennessee Linda D. Taylor, PhD(c), RN, OCN 24 Rockford, Illinois Lynn Tesh, MSN, RN Asheboro, North Carolina Vicki L. Vann, MS, ARNP Tampa, Florida Cheryl J. Vitacco-Grab, MSN, RNC Lancaster, Pennsylvania Loretta A. Wack, MSN, PNP, FNP Weyers Cave, Virginia Mary Hauser Whitaker, MSN, RN Richmond, Kentucky Cheryle I. Whitney, MSN, RN The Woodlands, Texas Chris Winkelman, RN, PhD, CNP, CCRN Cleveland, Ohio Danette Wood, EdD, MSN, RN, CCRN Statesboro, Georgia Terry Yoesting, MS, RN Denison, Texas 25 Reviewers Carol Annesser, RN, MSN, BC, CNE Assistant Professor Nursing, Mercy College of Ohio Toledo, Ohio Marilee Aufdenkamp, RN, MS Assistant Professor Creighton University School of Nursing Hastings, Nebraska Margaret Barnes, MSN, RN Assistant Professor Indiana Wesleyan University Marion, Indiana Helen L. Brooks, RN, MSN, Ed Assistant Professor of Nursing Northwestern Connecticut Community College Winsted, Connecticut Jean Burt, MS, RN Instructor Wilbur Wright College Nursing Program Chicago, Illinois 26 Reitha Cabaniss, MSN, RN, CNE Nursing Director Bevill State Community College Jasper, Alabama Barbara Callahan, MEd, RN, NCC, CHSE Nursing Faculty Lenoir Community College Kinston, North Carolina Marguerite C. DeBello, MSN, RN, ACNS-BC, CNE Assistant Professor School of Nursing Eastern Michigan University Ypsilanti, Michigan Fern Deno, RN, MSN, CNE Nursing Instructor Anoka Ramsey Community College Coon Rapids, Minnesota Jill Duska, MSN, RN-BC Coordinator of Student Affairs/Instructor Trinity Health System School of Nursing Steubenville, Ohio Valerie Edwards, RN, MSN Associate Professor Passaic County Community College Paterson, New Jersey Mary Fabick, MSN, MEd, RN-BC, CEN Associate Professor of Nursing Milligan College Milligan College, Tennessee Margie Francisco, EdD(c), MSN, RN Nursing Professor 27 Illinois Valley Community College Oglesby, Illinois Susan Golden, MSN, RN Interim Dean of Health ENMU-Roswell Roswell, New Mexico Jessica Gonzales, RN, MSN Nursing Instructor North Seattle Community College Redmond, Washington Sheila Grossman, PhD, APRN, FNP-BC, FAAN Professor & FNP Track Coordinator Fairfield University School of Nursing Fairfield, Connecticut Jerry Harvey, MS, RN, BC Assistant Professor of Nursing Liberty University, Lynchburg, Virginia Brenda Hoshaw, MSN, ACNS-BC, APRN, LMT Assistant Professor of Nursing Grand View University Des Moines, Iowa Lynn D. Kennedy, MSN, RN, AANN Assistant Professor of Nursing Francis Marion University Florence, South Carolina Mary Ann Kolis, MSN, ANP-BC Retired Gateway Technical College Kenosha, Wisconsin Lynn Korvick, PhD, RN, CNE 28 Chair of Nursing Missouri Southern State University Joplin, Missouri Karen Mehelich Lettre, RN, MSN, CEN, CPEN, EMT Pediatric Emergency Department Manager Children’s Medical Center Dallas Legacy Campus Frisco, Texas Sue A. McCann, MSN, RN, DNC Advanced Practice Nurse Clinical Research Coordinator University of Pittsburgh Medical Center Presbyterian-Shadyside Pittsburgh, Pennsylvania Kassie McKenny, MSN, RN, CNE Associate Professor Undergraduate Nursing Clarkson College Omaha, Nebraska Tara McMillan-Queen, RN, MSN, ANP, GNP Faculty II Mercy School of Nursing Charlotte, North Carolina Linda Mollino, MSN, RN Nursing Instructor Oregon Coast Community College Newport, Oregon Arlene Morris, EdD, MSN, CNE, RN Professor of Nursing Auburn University Montgomery Montgomery, Alabama Robin K. Moyers, PhD(c), RN-BC Nursing Educator Carl Vinson VA Medical Center 29 Dublin, Georgia Heather Pollet, BSN, RN Interim Nursing Director Coffeyville Community College Nursing Program Coffeyville, Kansas Katherine Roberts, MSN Assistant Professor of Nursing Lamar University Beaumont, Texas Karen Robertson, RN, BSN, MSN, MBA Associate Professor Rock Valley College Rockford, Illinois A. Joanna Seamans, MSN, RN Faculty Member Baptist Health System School of Health Professions San Antonio, Texas Valerie Steiner, RNC, MA, MSN, CNE Faculty Midland College Midland, Texas Anne Van Landingham, RN, BSN, MSN Nursing Instructor Orlando Technical College Orlando, Florida Michael Walls, MSN, PhD, RN Assistant Professor Manager, Medical-Surgical Nursing Malek School of Health Professions, Marymount University Arlington, Virginia 30 Daryle Wane, PhD, ARNP, FNP-BC Professor of Nursing Pasco-Hernando Community College New Port Richey, Florida Julia Ward, PhD, RN Assistant Professor Thomas Jefferson University Philadelphia, Pennsylvania Carol Warner, MSN, RNC, CPN, CRNP Instructor St. Luke’s School of Nursing Bethlehem, Pennsylvania Donna Wilsker, MSN, RN Assistant Professor Lamar University, Dishman Department of Nursing Beaumont, Texas Ruth A. Wittmann-Price, PhD, RN, CNE, Perinatal CNS Professor Chair, Department of Nursing Francis Marion University Florence, South Carolina Nancee Wozney, PhD, RN Dean of Nursing Allied Health Minnesota State College-Southeast Technical, Winona, Minnesota 31 Preface “To laugh often and much, to appreciate beauty, to find the best in others, to leave the world a bit better, to know that even one life has breathed easier because you have lived, this is to have succeeded.” —Ralph Waldo Emerson 32 Welcome to Saunders Pyramid to Success! 33 An Essential Resource for Test Success Saunders Comprehensive 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 will provide you with a comprehensive review of all of the nursing content areas specifically related to the new 2013 test plan for the NCLEX-RN examination, which is implemented by the National Council of State Boards of Nursing. This resource will help you achieve success on your nursing examinations during nursing school and on the NCLEX-RN examination. 34 Organization This book contains 20 units and 77 chapters. The chapters are designed to identify specific components of nursing content, and they contain practice questions, including a critical thinking question and both multiple choice and alternate item formats, that reflect the chapter content and the 2013 test plan for the NCLEX-RN exam. The final unit contains a 75-question Comprehensive Test. The new test plan identifies a framework based on Client Needs. These Client Needs categories include Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity. Integrated Processes are also identified as a component of the test plan. These include Caring, Communication and Documentation, Nursing Process, and Teaching and Learning. All the chapters address the components of the test plan framework. 35 Special Features of the Book Pyramid Terms Each unit begins with Pyramid Terms and their definitions. These Pyramid Terms are important to the discussion of the content in the chapters in the unit. Therefore they are in bold green type throughout the content section of each chapter. Pyramid to Success The Pyramid to Success, a feature part of the unit introduction, provides you with an overview, guidance, and direction regarding the focus of review in the particular content area, as well as the content area’s relative importance to the 2013 test plan for the NCLEX- RN exam. The Pyramid to Success reviews the Client Needs as they pertain to the content in that unit or chapter. These points identify the specific components to keep in mind as you review the chapter. Pyramid Points Pyramid Points are the little icons that are placed next to specific content throughout the chapters. The Pyramid Points highlight content that is important for preparing for the NCLEX-RN examination and identify content that typically appears on the NCLEX-RN examination. Pyramid Alerts Pyramid Alerts are the red text found throughout the chapters that alert you to important information about nursing concepts. These alerts identify content that typically appears on the NCLEX-RN examination. 36 Priority Nursing Actions Numerous Priority Nursing Actions boxes have been placed throughout the chapters. These boxes present a clinical nursing situation and the priority actions to take in the event of its occurrence. A rationale is provided that explains the correct order of action, along with a reference for additional research. Critical Thinking: What Should You Do? Questions Each chapter contains a Critical Thinking: What Should You Do? question. These questions provide a brief clinical scenario related to the content of the chapter and ask you what you should do about the client situation presented. A narrative answer is provided along with a reference source for researching further information. 37 Practice Questions While preparing for the NCLEX-RN examination, it is crucial for students to practice taking test questions. This book contains 1035 NCLEX-style multiple-choice and alternate item format questions. Multiple-Choice and Alternate Item Format Questions Starting with Unit II, each chapter is followed by a practice test. Each practice test contains several multiple-choice questions and an alternate item format question. The alternate item format questions at the end of the chapters may be presented as one of the following: Fill-in-the-blank question Multiple response question Figure/illustration question, also known as a hot spot question Graphic options question, in which each option contains a figure or illustration Chart/exhibit question These questions provide you with practice in prioritizing, decision-making, and critical thinking skills. Answer Section The answer sections include the correct answer, rationale, test-taking strategy, question categories, and reference. The structure for the answer section is unique and provides the following information: Rationale: The rationale provides you with the significant information regarding both correct and incorrect options. 38  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 on which you 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. Specific suggestions for review are identified in the test-taking strategy and are highlighted in bold magenta type to provide you direction for locating the specific content in this book. The highlighting of the specific test-taking strategies and specific content areas in the practice questions will provide you with guidance on what topics to review for further remediation in Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam and Saunders Comprehensive Review for the NCLEX-RN® Exam. Question Categories: Each question is tagged with categories based on the 2013 NCLEX-RN test plan. Additional content categories are provided with each question to assist you in identifying areas in need of review. The categories identified with each practice question include Level of Cognitive Ability, Client Needs, Integrated Process, and the specific nursing Content Area. New to this edition is a Priority Concepts code, which provides you with the specific concepts related to nursing practice. All categories are identified by their full names so that you do not need to memorize codes or abbreviations. Reference: A reference, including a page number, is provided so you can easily find the information that you need to review in your undergraduate nursing textbooks. 39 Pharmacology and Medication Calculations Review Students consistently state that pharmacology is an area with which they need assistance. The 2013 NCLEX-RN test plan continues to incorporate pharmacology in the examination as it has in the past. Therefore pharmacology chapters have been included for your review and practice. This book includes 13 pharmacology chapters, a medication and intravenous calculation chapter, and a pediatric medication calculation chapter. Each of these chapters is followed by a practice test that uses the same question format described earlier. This book contains numerous pharmacology questions. 40 How to Use This Book Saunders Comprehensive Review for the NCLEX-RN® Examination is especially designed to help you with your successful journey to the peak of the Saunders Pyramid to Success: becoming a registered nurse! As you begin your journey through this book, you will be introduced to all the important points regarding the 2013 NCLEX-RN examination, the process of testing, and unique and special tips regarding how to prepare yourself for this very important examination. You should begin your process through the Saunders Pyramid to Success by reading all of Unit I in this book and becoming familiar with the central points regarding the NCLEX- RN examination. Read Chapter 4, written by a nursing graduate who recently passed the examination and note what he has to say about the testing experience. Chapter 5 will provide you with the critical testing strategies that will guide you in selecting the correct option or assist you in selecting an answer to a question if you must guess. Keep these strategies in mind as you proceed through this book. Continue by studying the specific content areas addressed in Units II through XIX. Review the Pyramid Terms and Pyramid to Success notes, and identify the Client Needs specific to the test plan in each area. Read through the chapters and focus on the Pyramid Points and Pyramid Alerts that identify the areas most likely to be tested on the NCLEX-RN examination. Pay particular attention to the Priority Nursing Actions boxes because they provide information about the steps that you will take in clinical situations requiring prioritization. As you read each chapter, identify your areas of strength and those in need of further review. Highlight these areas and test your abilities by answering the Critical Thinking: What Should You Do? question and taking all the practice tests provided at the end of the 41 chapters. Be sure to review all the rationales and the test-taking strategies. The rationale provides you with information regarding both the correct and incorrect options. The test- taking strategy highlights the specific strategy in bold blue type and offers a logical path to selecting the correct option. The test-taking strategy also provides the content to review, highlighted in bold magenta type. Use the references to easily find any information you need to review. After reviewing all the chapters in the book, turn to Unit XX, the Comprehensive Test. Take this examination and then review each question, answer, and rationale. Identify any areas requiring further review; then take the time to review those areas again in both the book. 42 Climbing the Pyramid to Success The purpose of this book 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. After using this book for comprehensive content review, your next 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 5800 unique practice questions. 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. For on-the-go Q&A review, you can pick up Saunders Q&A Review Cards for the NCLEX-RN® Examination, or, if you own an iPhone or iPod Touch, you can search for “Saunders Q&A Review” in Apple’s App Store. 43  Your final step on the Pyramid to Success is to master the online review. 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, animations, audio, illustrations, testlets, and several subject matter exams. End of module practice tests are provided along with several Crossing the Finish Line practice tests. In addition, you can assess your progress with a pre-test and comprehensive exam in a computerized environment that prepares you for the actual NCLEX-RN exam. At the base of the Pyramid to Success are my test-taking strategies, which provide a foundation for understanding and unpacking the complexities of NCLEX exam questions, including alternate item formats. Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam takes a detailed look at all the test-taking strategies you will need to know in order to pass any nursing examination, including the NCLEX. Special tips are integrated for beginning nursing students, and there are more questions included so you can apply the testing strategies. Good luck with your journey through the Saunders Pyramid to Success. I wish you continued success throughout your new career as a registered nurse! Linda Anne Silvestri 44 Acknowledgments Sincere appreciation and warmest thanks are extended to the many individuals who in their own ways have contributed to the publication of this book. First, I want to thank all my nursing students at the Community College of Rhode Island in Warwick who approached me in 1991 and persuaded me to help them prepare 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 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 helped nursing students achieve success with the exam. Additionally, I want to acknowledge and sincerely thank my husband Laurent W. Valliere, or Larry, for his contribution to this publication, for teaching in my review courses for the NCLEX-RN exam, and for his commitment and dedication in helping my nursing students prepare for the NCLEX-RN exam from a nonacademic point of view. Larry has supported my many professional 45 endeavors and was so loyal and loving to me each and every moment as I worked to achieve my professional goals. Larry, thank you so much! A special thank you also goes to David Morrow, RN, BSN, for writing a chapter for this book about his experiences preparing for and taking the NCLEX-RN examination. I sincerely acknowledge and thank two very important individuals from Elsevier who are so dedicated to my work in creating NCLEX products for nursing students. I thank Kristin Geen, Executive Content Strategist, for her continuous assistance, enthusiasm, support, and expert professional guidance as I prepared this publication. And I thank Laura Goodrich, Associate Content Developmental Specialist, for her tremendous amount of support and assistance, her weekly priority lists to keep me on track, her ideas for the product, and for her professional and expert skills in organizing and maintaining an enormous amount of manuscript for production. I could not have completed this project without Laura! So a very special and sincere thank you extends to both Kristin and Laura. I also thank Angela E. Silvestri, MSN, RN for reviewing content and practice questions and for her assistance with creating new practice questions; Dr. Eileen Gray for her assistance in reviewing practice questions submitted by item updaters; Elodia Dianne Fiorentino for researching content and preparing references for each practice question; Nicholas Silvestri and Allison Bowser for editing, formatting, and organizing manuscript files for me; and James Guilbault for researching and updating medications. A special thank you to all of you for providing continuous support and dedication to my work in preparing this publication and maintaining its excellent quality. I want to acknowledge all of the staff at Elsevier for their tremendous assistance throughout the preparation and production of this publication and all of the Elsevier staff involved in the publication of previous editions of this outstanding NCLEX review product. A special thank you to all of them. I thank all the important people in the 46 production department, including Clay Broeker, Senior Project Manager; Jeff Patterson, Publishing Services Manager; Lisa Godoski, Multimedia Producer; David Rushing, Multimedia Manager; and Brian Salisbury, Designer, who all played such significant roles in finalizing this publication. Also, I would like to thank Hannah Corrier, Content Coordinator, for all her help organizing the numerous contributors and reviewers involved in this project. I sincerely thank those in the marketing department who helped with the promotion of this book, including Bob Boehringer, Executive Marketing Director; Pat Crowe, Executive Marketing Manager; and Danielle LeCompte, Associate Marketing Manager. And a special thank you to Loren Wilson, Vice President, for her years of expert guidance and continuous support for all the products in the Pyramid to Success. I would also like to acknowledge Patricia Mieg, former educational sales representative, who encouraged me to submit my ideas and initial work for the first edition of this book to the W.B. Saunders Company. I want to acknowledge my parents, who opened my door of opportunity in education. 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. My memories of his love and support will always remain in my heart. I am certain that he would be very proud of my professional accomplishments. I also thank all my family for being continuously supportive, giving, and helpful during my research and preparation of this publication. I want to especially acknowledge each and every individual who contributed to this publication: the contributors, item writers, and updaters for your expert input and ideas. I also thank the many faculty and student reviewers of the manuscript for their thoughts and ideas. A very special thank you to all of you! 47  I also need to thank Salve Regina University for the opportunity to educate nursing students in the baccalaureate nursing program and for its support during my research and writing of this publication. I would like to especially acknowledge my colleagues, Dr. Eileen Gray, Dr. Ellen McCarty, and Dr. Bethany Sykes for all their encouragement and support. I wish to acknowledge the Community College of Rhode Island, which provided me the opportunity to educate nursing students in the Associate Degree of Nursing Program. A special thank you goes to Patricia Miller, MSN, RN, and Michelina McClellan, MS, RN, from Baystate Medical Center, School of Nursing, in Springfield, Massachusetts, who were my first mentors in nursing education. Lastly, a very special thank you to all my nursing students—past, present, and future. All of you light up my life! Your love and dedication to the profession of nursing and your commitment to provide health care will bring never ending rewards! Linda Anne Silvestri 48 Contents Title Page Copyright Dedication To All Future Registered Nurses About the Author Contributors Reviewers Preface Acknowledgments UNIT I NCLEX-RN® Exam Preparation 1 The NCLEX-RN® Examination 2 NCLEX-RN® Preparation for Foreign-Educated Nurses: Transitional Issues for Foreign-Educated Nurses 3 Pathways to Success 49  4 The NCLEX-RN® Examination: From a Graduate’s Perspective 5 Test-Taking Strategies UNIT II Issues in Nursing 6 Cultural Awareness and Health Practices 7 Ethical and Legal Issues 8 Prioritizing Client Care: Leadership, Delegation, and Disaster Planning UNIT III Nursing Sciences 9 Fluids and Electrolytes 10 Acid-Base Balance 11 Laboratory Values 12 Nutrition 13 Parenteral Nutrition 14 Intravenous Therapy 15 Administration of Blood Products UNIT IV Fundamental Skills 16 Provision of a Safe Environment 17 Calculation of Medication and Intravenous Prescriptions 50 18 Cardiopulmonary Resuscitation Guidelines for Health Care Providers 19 Perioperative Nursing Care 20 Positioning Clients 21 Care of a Client with a Tube UNIT V Growth and Development across the Life Span 22 Theories of Growth and Development 23 Developmental Stages 24 Care of the Older Client 25 Health and Physical Assessment of the Adult Client UNIT VI Maternity Nursing 26 Reproductive System 27 Obstetrical Assessment 28 Prenatal Period 29 Risk Conditions Related to Pregnancy 30 Labor and Delivery 31 Problems with Labor and Delivery 32 Postpartum Period 33 Postpartum Complications 34 Care of the Newborn 51 35 Maternity and Newborn Medications UNIT VII Pediatric Nursing 36 Integumentary Disorders 37 Hematological Disorders 38 Oncological Disorders 39 Metabolic and Endocrine Disorders 40 Gastrointestinal Disorders 41 Eye, Ear, and Throat Disorders 42 Respiratory Disorders 43 Cardiovascular Disorders 44 Renal and Urinary Disorders 45 Neurological and Cognitive Disorders 46 Musculoskeletal Disorders 47 Acquired Immunodeficiency Syndrome 48 Infectious and Communicable Diseases 49 Pediatric Medication Administration and Calculations UNIT VIII Integumentary Disorders of the Adult Client 50 Integumentary System 51 Integumentary Medications 52 UNIT IX Hematological and Oncological Disorders of the Adult Client 52 Hematological and Oncological Disorders 53 Antineoplastic Medications UNIT X Endocrine Disorders of the Adult Client 54 Endocrine System 55 Endocrine Medications UNIT XI Gastrointestinal Disorders of the Adult Client 56 Gastrointestinal System 57 Gastrointestinal Medications UNIT XII Respiratory Disorders of the Adult Client 58 Respiratory System 59 Respiratory Medications UNIT XIII Cardiovascular Disorders of the Adult Client 60 Cardiovascular System 53 61 Cardiovascular Medications UNIT XIV Renal and Urinary Disorders of the Adult Client 62 Renal System 63 Renal Medications UNIT XV Eye and Ear Disorders of the Adult Client 64 The Eye and the Ear 65 Ophthalmic and Otic Medications UNIT XVI Neurological Disorders of the Adult Client 66 Neurological System 67 Neurological Medications UNIT XVII Musculoskeletal Disorders of the Adult Client 68 Musculoskeletal System 69 Musculoskeletal Medications UNIT XVIII 54 Immune Disorders of the Adult Client 70 Immune Disorders 71 Immunological Medications UNIT XIX Mental Health Disorders of the Adult Client 72 Foundations of Psychiatric Mental Health Nursing 73 Models of Care 74 Mental Health Disorders 75 Addictions 76 Crisis Theory and Intervention 77 Psychiatric Medications UNIT XX Comprehensive Test References Index 55 UNIT I NCLEX-RN® Exam Preparation 56  CHAPTER 1 The NCLEX-RN® Examination 57 The Pyramid to Success Welcome to the Pyramid to Success Saunders Comprehensive Review for the NCLEX-RN® Examination Saunders Comprehensive Review for the NCLEX-RN® Examination is specially designed to help you begin your successful journey to the peak of the pyramid, becoming a registered nurse. As you begin your journey, you will be introduced to all the important points regarding the NCLEX-RN examination and the process of testing, and to the unique and special tips regarding how to prepare yourself for this important examination. You will read what a nursing graduate who recently passed the NCLEX-RN examination has to say about the test. Important test-taking strategies are detailed. These details will guide you in selecting the correct option or assist you in selecting an answer to a question at which you must guess. Each unit in this book begins with the Pyramid to Success. The Pyramid to Success addresses specific points related to the NCLEX-RN examination, including the Pyramid Terms, and the Client Needs as identified in the test plan framework for the examination. Pyramid Terms are key words that are defined and are set in color throughout each chapter to direct your attention to significant points for the examination. The Client Needs specific to the content of the unit are identified. Throughout each chapter, you will find Pyramid Point bullets that identify areas most likely to be tested on the NCLEX-RN examination. Read each chapter, and identify your strengths and areas that are in need of further review. Test your strengths and abilities by taking all the practice tests provided in this book and on the accompanying Evolve site. Be 58 sure to read all the rationales and test-taking strategies. The rationale provides you with significant information regarding the correct and incorrect options. The test-taking strategy provides you with the logical path to selecting the correct option. The test-taking strategy also identifies the content area to review, if required. The reference source and page number are provided so that you can find the information easily that you need to review. Each question is coded on the basis of the Level of Cognitive Ability, the Client Needs category, the Integrated Process, and the nursing content area. Following the completion of your comprehensive review in this book, continue on your journey through the Pyramid to Success with the companion book, Saunders Q&A Review for the NCLEX-RN® Examination. This book provides you with practice questions in the multiple-choice and alternate item formats. The book is designed based on the NCLEX- RN examination test plan framework, with a specific focus on Client Needs and Integrated Processes. In addition, each practice question in this book includes a Priority Nursing Tip, which provides you with an important piece of information that will be helpful to answer questions. Then, you will be ready for HESI/Saunders Online Review for the NCLEX-RN® Examination. Additional products in Saunders Pyramid to Success include Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam and Saunders Q&A Review Cards for the NCLEX-RN® Exam. These products are described next. HESI/Saunders Online Review for the NCLEX-RN® Examination This product addresses all areas of the test plan identified by the National Council of State Boards of Nursing (NCSBN). The course contains a pretest that provides feedback regarding your strengths and weaknesses and generates an individualized study schedule in a calendar format. Content review is in an outline format and includes self-check practice 59 questions and testlets (case studies), figures and illustrations, a glossary, and animations and videos. Numerous online exams are included. There are 2500 practice questions; the types of questions in this course include multiple-choice and alternate item formats. Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam This product focuses on the test-taking strategies that will help you pass your nursing examinations while in nursing school and will prepare you for the NCLEX-RN examination. The chapters describe various test-taking strategies and include sample questions that illustrate how to use the strategies. Also included in this book is information on cultural characteristics and practices, pharmacology strategies, medication and intravenous calculations, laboratory values, positioning guidelines, and therapeutic diets. This book has practice questions, and each question provides a tip for the beginning nursing student. The practice questions reflect the framework and the content identified in the NCLEX-RN test plan and includes multiple-choice and alternate item format questions, including audio and video questions. Saunders Q&A Review Cards for the NCLEX-RN® Exam This product is organized by content areas and the test plan framework of the NCLEX-RN test plan. It provides you with 1200 unique practice test questions on portable and easy-to- use cards. The cards have the question on the front of the card, and the answer, rationale, and test-taking strategy are on the back of the card. This product includes multiple-choice questions and alternate item format questions, including fill-in-the-blank, multiple- response, ordered-response, figure, and chart/exhibit questions. All the products in the Saunders Pyramid to Success can be obtained online by visiting 60 http://elsevierhealth.com or by calling 800-545-2522. Let’s begin our journey through the Pyramid to Success. 61 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 addresses the procedures related to the development of the NCLEX-RN examination test plan, the components of the test plan, and the answers to the questions most commonly asked by nursing students and graduates preparing to take the NCLEX. The information contained in this chapter related to the test plan was obtained from the NCSBN Web site (http://www.ncsbn.org) and from the NCSBN 2013 test plan for the NCLEX-RN. You can obtain additional information regarding the test and its development by accessing the NCSBN Web site or by writing to the National Council of State Boards of Nursing, 111 East Wacker Drive, Suite 2900, Chicago, IL 60601. You are encouraged to access the NCSBN Web site because this site provides you with valuable information about the NCLEX and other resources available to an NCLEX candidate. 62 Computer Adaptive Testing The acronym CAT stands for computer 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 the test plan requirements are met and a reliable pass-or-fail decision is made. When a test question is presented on the computer screen, you must answer it or the test will not move on. This means that you will not be able to skip questions, go back and review questions, or go back and change answers. In a CAT examination, 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. There is no penalty for guessing on this examination. With most of the questions, the answer will be right there in front of you. If you need to guess, use your nursing knowledge and clinical experiences to their fullest extent and all the test-taking strategies that you have practiced in this review program. You do not need any computer experience to take this examination. A keyboard tutorial 63 is provided and administered to all test-takers at the start of the examination. The tutorial will instruct you on the use of the on-screen optional calculator, the use of the mouse, and how to record an answer. The tutorial provides instructions on how to respond to all question types on this examination. This tutorial is provided on the NCSBN Web site, and 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. 64  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, to determine the framework for the test plan for the examination. The participants in this study include newly licensed registered nurses from all types of basic nursing education programs. From a list of nursing care activities provided, the participants are asked about the frequency and importance of performing them in relation to client safety and the setting in which they are performed. A panel of content experts at the NCSBN analyzes the results of the study and makes decisions regarding the test plan framework. The results of this recently conducted study provided the structure for the test plan implemented in April 2013. 65 Item Writers The NCSBN selects question (item) writers after an extensive application process. The writers are registered nurses who hold a master’s degree or a higher degree and many of the writers are nursing educators. Question writers voluntarily submit an application to become a writer and must meet specific criteria established by the council to be accepted as participants in the process. 66 Test Plan The content of the NCLEX-RN examination reflects the activities identified in the practice analysis study conducted by the NCSBN. The questions are written to address Level of Cognitive Ability, Client Needs, and Integrated Processes as identified in the test plan developed by the NCSBN. Level of Cognitive Ability The practice of nursing requires critical thinking in decision making. Most questions on the NCLEX examination are written at the application level or at higher Levels of Cognitive Ability, such as the analysis level. Box 1-1 presents an example of a question that requires you to apply data. BOX 1-1 Level of Cognitive Ability: Applying The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On the basis of these findings, the nurse should implement which action? 1. Discontinue the IV 2. Apply a warm compress 3. Check for a blood return 4. Measure the area of infiltration Answer: 1 This question requires that you focus on the data in the question and determine that the client is experiencing an infiltration. Next, you need to consider the harmful effects of infiltration and determine the action to implement. Because infiltration can be 67  damaging to the surrounding tissue, the appropriate action is to discontinue the IV to prevent any further damage. Client Needs In the test plan implemented in April 2013, the NCSBN has identified a test plan framework based on Client Needs. The NCSBN identifies four major categories of Client Needs. Some of these categories are divided further into subcategories. The Client Needs categories include Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity (Table 1-1). TABLE 1-1 Client Needs Categories and Percentage of Questions on the NCLEX-RN® Examination Client Needs Category Percentage of Questions Safe and Effective Care Environment Management of Care 17-23 Safety and Infection Control 9-15 Health Promotion and Maintenance 6-12 Psychosocial Integrity 6-12 Physiological Integrity Basic Care and Comfort 6-12 Pharmacological and Parenteral Therapies 12-18 Reduction of Risk Potential 9-15 Physiological Adaptation 11 -17 Safe and Effective Care Environment The Safe and Effective Care Environment category includes two subcategories: Management of Care, and Safety and Infection Control. According to the NCSBN, Management of Care (17% to 23% of questions) addresses content that tests the nurse’s knowledge, skills, and ability required to ensure a safe care delivery setting to protect clients, families, significant others, visitors, and health care personnel. The NCSBN 68 indicates that Safety and Infection Control (9% to 15% of questions) addresses content that tests the nurse’s knowledge, skills, and ability required to protect clients, families, significant others, visitors, and health care personnel from health and environmental hazards. Box 1-2 presents examples of questions that address these two subcategories. BOX 1-2 Safe and Effective Care Environment Management of Care The nurse has received the client assignment for the day. Which client should the nurse assess first? 1. The client who has a nasogastric tube attached to intermittent suction 2. The client who needs to receive subcutaneous insulin before breakfast 3. The client who is 2 days postoperative and is complaining of incisional pain 4. The client who has a blood glucose level of 50 mg/dL and complaints of blurred vision Answer: 4 This question addresses the subcategory Management of Care in the Client Needs category Safe and Effective Care Environment. It requires you to establish priorities by comparing the needs of each client and deciding which need is urgent. The client described in the correct option has a low blood glucose level and symptoms reflective of hypoglycemia. This client should be assessed first so that treatment can be implemented. Although the clients in options 1, 2, and 3 have needs that require assessment, their assessments can wait until the client in the correct option is stabilized. Safety and Infection Control The nurse prepares to care for a client on contact precautions who has a hospital- 69  acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. The nurse should assemble which necessary protective items before entering the client’s room? 1. Gloves and a gown 2. Gloves, mask, and goggles 3. Gloves, mask, gown, and goggles 4. Gloves, gown, and shoe protectors Answer: 3 This question addresses the subcategory Safety and Infection Control in the Client Needs category Safe and Effective Care Environment. It addresses content related to protecting oneself from contracting an infection and requires that you consider the methods of possible transmission of infection, based on the client’s condition. Because splashes of infective material can occur during the wound irrigation or suctioning of the tracheostomy, option 3 is correct. Health Promotion and Maintenance The Health Promotion and Maintenance category (6% to 12% of questions) addresses the principles related to growth and development. According to the NCSBN, this Client Needs category also addresses content that tests the nurse’s knowledge, skills, and ability required to assist the client, family members, and significant others to prevent health problems; to recognize alterations in health; and to develop health practices that promote and support wellness. See Box 1-3 for an example of a question in this Client Needs category. BOX 1-3 Health Promotion and Maintenance 70  The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this age? 1. Puzzle 2. Toy soldiers 3. Large stacking blocks 4. A card game with large pictures Answer: 3 This question addresses the Client Needs category Health Promotion and Maintenance and specifically relates to the principles of growth and development of a toddler. Toddlers like to master activities independently, such as stacking blocks. Because toddlers do not have the developmental ability to determine what could be harmful, toys that are safe need to be provided. A puzzle and toy soldiers provide objects that can be placed in the mouth and may be harmful for a toddler. A card game with large pictures may require cooperative play, which is more appropriate for a school-age child. Psychosocial Integrity The Psychosocial Integrity category (6% to 12% of questions) addresses content that tests the nurse’s knowledge, skills, and ability required to promote and support the ability of the client, client’s family, and client’s significant other to cope, adapt, and problem solve during stressful events. The NCSBN also indicates that this Client Needs category addresses the emotional, mental, and social well-being of the client, family, or significant other, and the knowledge, skills, and ability required to care for the client with an acute or chronic mental illness. See Box 1-4 for an example of a question in this Client Needs category. 71  BOX 1-4 Psychosocial Integrity A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which client statement indicates an understanding of this stress reduction measure? 1. “This will help only if I play music at the same time.” 2. “This will work for me only if I am alone in a quiet area.” 3. “I need to do this only when I lie down in case I fall asleep.” 4. “The best thing about this is that I can use it anywhere, anytime.” Answer: 4 This question addresses the Client Needs category Psychosocial Integrity and the content addresses coping mechanisms. Guided imagery involves the client’s creation of an image in the mind, concentrating on the image, and gradually becoming less aware of the offending stimulus. It can be done anytime and anywhere; some clients may use other relaxation techniques or play music with it. Physiological Integrity The Physiological Integrity category includes four subcategories: Basic Care and Comfort, Pharmacological and Parenteral Therapies, Reduction of Risk Potential, and Physiological Adaptation. The NCSBN describes these subcategories as follows. Basic Care and Comfort (6% to 12% of questions) addresses content that tests the nurse’s knowledge, skills, and ability required to provide comfort and assistance to the client in the performance of activities of daily living. Pharmacological and Parenteral Therapies (12% to 18% of questions) addresses content that tests the nurse’s knowledge, skills, and ability required to administer medications and parenteral therapies such as intravenous therapies and 72 parenteral nutrition, and the administration of blood and blood products. Reduction of Risk Potential (9% to 15% of questions) addresses content that tests the nurse’s knowledge, skills, and ability required to prevent complications or health problems related to the client’s condition or any prescribed treatments or procedures. Physiological Adaptation (11% to 17% of questions) addresses content that tests the nurse’s knowledge, skills, and ability required to provide care to clients with acute, chronic, or life-threatening conditions. See Box 1-5 for examples of questions in this Client Needs category. BOX 1-5 Physiological Integrity Basic Care and Comfort A client with Parkinson’s disease develops akinesia while ambulating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem? 1. Use a wheelchair to move around. 2. Stand erect and use a cane to ambulate. 3. Keep the feet close together while ambulating and use a walker. 4. Consciously think about walking over imaginary lines on the floor. Answer: 4 This question addresses the subcategory Basic Care and Comfort in the Client Needs category Physiological Integrity, and addresses client mobility and promoting assistance in an activity of daily living to maintain safety. Clients with Parkinson’s disease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these clients imagine lines on the floor to walk over can keep them moving forward while remaining safe. 73 Pharmacological and Parenteral Therapies The nurse monitors a client receiving digoxin (Lanoxin) for which early manifestation of digoxin toxicity? 1. Anorexia 2. Facial pain 3. Photophobia 4. Yellow color perception Answer: 1 This question addresses the subcategory Pharmacological and Parenteral Therapies in the Client Needs category Physiological Integrity. Digoxin is a cardiac glycoside that is used to manage and treat heart failure and to control ventricular rates in clients with atrial fibrillation. The most common early manifestations of toxicity include gastrointestinal disturbances such as anorexia, nausea, and vomiting. Neurological abnormalities can also occur early and include fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares. Facial pain, personality changes, and ocular disturbances (photophobia, diplopia, light flashes, halos around bright objects, yellow or green color perception) are also signs of toxicity, but are not early signs. Reduction of Risk Potential A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. The nurse should implement which action to prepare the client for this test? 1. Shave the groin for insertion of a femoral catheter. 2. Remove all metal-containing objects from the client. 3. Keep the client NPO (nil per os; nothing by mouth) for 6 hours before the test. 74  4. Instruct the client in inhalation techniques for the administration of the radioisotope. Answer: 2 This question addresses the subcategory Reduction of Risk Potential in the Client Needs category Physiological Integrity, and the nurse’s responsibilities in preparing the client for the diagnostic test. In an MRI study, radiofrequency pulses in a magnetic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, and watches, should be removed. In addition, a history should be taken to ascertain whether the client has any internal metallic devices, such as orthopedic hardware, pacemakers, or shrapnel. For an abdominal MRI study, the client may need to be NPO. NPO status is not necessary for an MRI study of the head. The groin may be shaved for an angiogram, and inhalation of the radioisotope may be prescribed with a positron emission tomography (PET) scan or ventilation/perfusion lung scan. Physiological Adaptation A client with renal insufficiency has a magnesium level of 3.6 mg/dL. On the basis of this laboratory result, the nurse interprets which sign as significant? 1. Hyperpnea 2. Drowsiness 3. Hypertension 4. Physical hyperactivity Answer: 2 This question addresses the subcategory Physiological Adaptation in the Client Needs category Physiological Integrity. It addresses an alteration in body systems. The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 3.6 mg/dL indicates 75  hypermagnesemia. Neurological manifestations begin to occur when magnesium levels are elevated and are noted as symptoms of neurological depression, such as drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia. Bradycardia and hypotension also occur. Integrated Processes The NCSBN identifies four processes in the test plan that are fundamental to the practice of nursing. These processes are incorporated throughout the major categories of Client Needs. The Integrated Process subcategories include Caring, Communication and Documentation, Nursing Process (Assessment, Analysis, Planning, Implementation, and Evaluation), and Teaching and Learning. See Box 1-6 for an example of a question that incorporates the Integrated Process of Caring. BOX 1-6 Integrated Processes A client is scheduled for angioplasty. The client says to the nurse, “I’m so afraid that it will hurt and will make me worse off than I am.” Which response by the nurse is therapeutic? 1. “Can you tell me what you understand about the procedure?” 2. “Your fears are a sign that you really should have this procedure.” 3. “Those are very normal fears, but please be assured that everything will be okay.” 4. “Try not to worry. This is a well-known and easy procedure for the health care provider.” Answer: 1 This question addresses the subcategory Caring in the category Integrated Processes. 76 The correct option is a therapeutic communication technique that explores the client’s feelings, determines the level of client understanding about the procedure, and displays caring. Option 2 demeans the client and does not encourage further sharing by the client. Option 3 does not address the client’s fears, provides false reassurance, and puts the client’s feelings on hold. Option 4 diminishes the client’s feelings by directing attention away from the client and to the health care provider’s importance. 77 Types of Questions on the Examination The types of questions that may be administered on the examination include multiple- choice; fill-in-the-blank; multiple-response; ordered-response (also known as drag and drop); questions that contain a figure, chart/exhibit, or graphic option item; and audio or video item formats. Some questions may require you to use the mouse and cursor on the computer. For example, you may be presented with a picture that displays the arterial vessels of an adult client. In this picture, you may be asked to “point and click” (using the mouse) on the area (hot spot) where the dorsalis pedis pulse could be felt. In all types of questions, the answer is scored as either right or wrong. Credit is not given for a partially correct answer. In addition, all question types may include pictures, graphics, tables, charts, sound, or video. The NCSBN provides specific directions for you to follow with all question types to guide you in your process of testing. 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. Multiple-Choice Questions Most 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 78 answer, this needs to be performed at the end of the calculation. The rules for rounding an answer are provided in the tutorial provided by the NCSBN, and are also provided in the specific question. In addition, you must type in a decimal point if necessary. See Box 1-7 for an example. BOX 1-7 Fill-in-the-Blank Question A prescription reads: acetaminophen (Tylenol Extra Strength) liquid, 650 mg orally every 4 hours PRN for pain. The medication label reads: 500 mg/15 mL. The nurse prepares how many milliliters to administer one dose? Fill in the blank. Answer: 19.5 mL Formula: In this question, you need to use the formula for calculating a medication dose. When the dose is determined, you will need to type your numeric answer in the answer box. Always follow the specific directions noted on the computer screen. Also, remember that there will be an on-screen calculator on the computer for your use. Multiple-Response Questions For a multiple-response question, you will be asked to select or check all the options, such as nursing interventions, that relate to the information in the question. In these question types, there may be two or more correct answers. No partial credit is given for correct selections. You need to do exactly as the question asks, which will be to select all the options that apply. See Box 1-8 for an example. 79  BOX 1-8 Multiple-Response Question The emergency department nurse is caring for a child suspected of acute epiglottitis. Which interventions apply in the care of the child? Select all that apply. 1. Obtain a throat culture. 2. Ensure a patent airway. 3. Prepare the child for a chest x-ray. 4. Maintain the child in a supine position. 5. Obtain a pediatric-size tracheostomy tray. 6. Place the child on an oxygen saturation monitor. In a multiple-response question, you will be asked to select or check all the options, such as interventions, that relate to the information in the question. To answer this question, recall that acute epiglottitis is a serious obstructive inflammatory process that requires immediate intervention and airway patency is a priority. Examination of the throat with a tongue depressor or attempting to obtain a throat culture is contraindicated because the examination can precipitate further obstruction. A lateral neck and chest x-ray is obtained to determine the degree of obstruction, if present. To reduce respiratory distress, the child should sit upright. The child is placed on an oxygen saturation monitor to monitor oxygenation status. Tracheostomy and intubation may be necessary if respiratory distress is severe. Remember to follow the specific directions given on the computer screen. Ordered-Response Questions In this type of question, you will be asked to use the computer mouse to drag and drop your nursing actions in order of priority. Information will be presented in a question, and, 80 based on the data, you need to determine what you will do first, second, third, and so forth. The unordered options will be located in boxes on the left side of the screen, and you need to move all options in order of priority to ordered-response boxes on the right side of the screen. Specific directions for moving the options are provided with the question. See Box 1-9 for an example. BOX 1-9 Ordered-Response Question The nurse is preparing to suction a client who has a tracheostomy tube and gathers the supplies needed for the procedure. Arrange in order of priority the actions that the nurse should take to perform this procedure. All options must be used. Unordered Options Ordered Responses Hyperoxygenate the client. Place the client in a semi-Fowler’s position. Place the client in a semi-Fowler’s Turn on the suction device and set the position. regulator at 80 mm Hg. Turn on the suction device and set the Apply gloves and attach the suction regulator at 80 mm Hg. tubing to the suction catheter. Apply gloves and attach the suction Hyperoxygenate the client. tubing to the suction catheter. Apply intermittent suction and slowly Insert the catheter into the tracheostomy withdraw the catheter while rotating it until resistance is met and then pull back and forth. back 1 cm. Insert the catheter into the tracheostomy Apply intermittent suction and slowly until resistance is met and then pull withdraw the catheter while rotating it back 1 cm. back and forth. This question requires you to arrange in order of priority the nursing actions that should be taken to suction a client who has a tracheostomy tube. The nurse positions the client first, and then turns the suction device on and sets the regulator. The nurse then dons gloves and attaches the suction tubing to the suction catheter. The nurse hyperoxygenates the client before and after suctioning. The nurse then inserts the 81  catheter into the tracheostomy until resistance is met and pulls back 1 cm, applies intermittent suction, and slowly withdraws the catheter while rotating it back and forth. Remember that the client and equipment are prepared before performing the procedure. Also, remember that on the NCLEX examination, you will use the computer mouse to place the unordered options in an ordered response. 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 1-10 for an example. BOX 1-10 Figure Question A client who experienced a myocardial infarction is being monitored via cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor (refer to figure) and immediately takes which action? Rhythm strip. (From Ignatavicius D, Workman M: Medical-surgical nursing: Patient- centered collaborative care, ed 7, Philadelphia, 2010, Saunders.) 82  1. Takes the client’s blood pressure 2. Initiates cardiopulmonary resuscitation (CPR) 3. Places a nitroglycerin tablet under the client’s tongue 4. Continues to monitor the client and then contacts the health care provider (HCP) Answer: 2 This question requires you to identify the cardiac rhythm, and then determine the priority nursing action. This cardiac rhythm identifies a coarse ventricular fibrillation (VF). The goals of treatment are to terminate VF promptly and to convert it to an organized rhythm. The HCP or an Advanced Cardiac Life Support (ACLS)–qualified nurse must immediately defibrillate the client. If a defibrillator is not readily available, CPR is initiated until the defibrillator arrives. Options 1, 3, and 4 are incorrect actions and delay life-saving treatment. Chart/Exhibit Questions In this type of question, you will be presented with a problem and a chart or exhibit. You will be provided with three 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 1-11 for an example. BOX 1-11 Chart/Exhibit Question 83  The nurse reviews the history and physical examination documented in the medical record of a client requesting a prescription for oral contraceptives. The nurse determines that oral contraceptives are contraindicated because of which documented item? Refer to chart. Answer: 2 This chart/exhibit question provides you with data from the client’s medical record and asks you to identify the item that is a contraindication to the use of oral contraceptives. Oral contraceptives are contraindicated in women with a history of any of the following: thrombophlebitis and thromboembolic disorders, cardiovascular or cerebrovascular diseases (including stroke), any estrogen-dependent cancer or breast cancer, benign or malignant liver tumors, impaired liver function, hypertension, and diabetes mellitus with vascular involvement. Adverse effects of oral contraceptives include increased risk of superficial and deep venous thrombosis, pulmonary embolism, thrombotic stroke (or other types of strokes), myocardial infarction, and accelerations of preexisting breast tumors. Graphic Option Questions In this type of question, the option selections will be pictures rather than text. Each option will be preceded by a circle, and you will need to use the computer mouse to click in the circle that represents your answer choice. See Box 1-12 for an example. 84 BOX 1-12 Graphic Options Question The nurse should place the client in which position to administer a soapsuds enema? (Refer to the figures in 1-4.) 1. (From Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby.) 2. (From Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby.) 3. (From Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby.) 4. (From Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 85  2013, Mosby.) Answer: 2 This question requires you to select the picture that represents your answer choice. To administer an enema, the nurse assists the client into the left side–lying (Sims) position with the right knee flexed. This position allows the enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum, improving the retention of solution. Option 1 is a prone position. Option 3 is a dorsal recumbent position. Option 4 is a supine position. 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. Video Questions Video questions will require viewing of an animation or video clip to answer the question. These questions will prompt you to click on the video icon. There may be sound associated with the animation and video, in which case you will be prompted to use the headset. Content examples include, but are not limited to, assessment techniques, nursing procedures, or communication skills. 86 Registering to Take the Examination It is important to obtain an NCLEX examination candidate bulletin from the NCSBN Web site at www.ncsbn.org because this bulletin provides all the information that you need to register for and schedule your examination. It also provides you with Web site 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. When you receive confirmation from the board of nursing that you have met all of the state requirements, you can register to take the NCLEX examination with Pearson VUE. You may register for the examination through the Internet, by U.S. mail, or by telephone. The NCLEX candidate Web site is http://www.pearsonvue.com/nclex. 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. You will then be made eligible by the licensure board and will receive an Authorization to Test (ATT) form. If you do not receive an ATT form within 2 weeks of registration, you should contact the candidate services at 1-866-496-2539 (U.S. candidates). 87 Authorization to Test Form and Scheduling an Appointment 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 examination will take place at a Pearson Professional Center; U.S. candidates can make an appointment through the Internet (http://www.pearsonvue.com/nclex) or by telephone (1-866-496-2539). You can schedule an appointment at any Pearson Professional Center. You do not have to take the examination in the same state in which you are seeking licensure. A confirmation of your appointment with the appointment date and time and the directions to the testing center will be sent to you. The ATT form contains important information, including your test authorization number, candidate identification number, and validity date. You need to take your ATT form to the test center on the day of your examination. You will not be admitted to the examination if you do not have it. 88 Changing Your Appointment If for any reason you need to change your appointment to test, you can make the change on the candidate Web site (http://www.pearsonvue.com/nclex) or by calling candidate services. The change needs to be made 1 full business day (24 hours) before your scheduled 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. 89 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 to that destination, and any potential obstacles that might delay you, such as road construction, traffic, or parking sites. You must have the ATT and proper identification (ID) 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 identification 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. 90 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 special testing accommodations. Following 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. 91 Testing Center The test center is designed to ensure complete security of the testing process. Strict candidate identification requirements have been established. You must bring the ATT form and required forms of identification. 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 test 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 an incident and a result 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 work space area that includes computer equipment, appropriate lighting, and erasable note board and a marker. No items, including unauthorized scratch paper, are allowed into the testing room. Eating, drinking, or the use of tobacco is 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 92 audio recordings of all test sessions are made. Pearson Professional Centers 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 test 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 candidate Web site (http://www.pearsonvue.com/nclex) to obtain additional information about the physical environment of the test center. 93 Testing Time The maximum testing time is 6 hours; this period includes the tutorial, the sample items, all breaks, and the examination. All breaks are optional. The first optional break will be offered after 2 hours of testing. The second optional break is offered after 3.5 hours of testing. Remember that all breaks count against testing time. If you take a break, you must leave the testing room and, when you return, you may be required to perform identity confirmation procedures to be readmitted. 94 Length of the Examination The minimum number of questions that you will need to answer is 75. Of these 75 questions, 60 will be operational (scored) questions and 15 will be pretest (unscored) questions. The maximum number of questions in the test is 265. Fifteen of the total number of questions that you need to answer will be pretest (unscored) questions. 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. 95  Pass-or-Fail Decisions All the 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. The NCSBN indicates that a pass or fail decision is governed by three different scenarios. The first scenario is the 95% Confidence Interval Rule, in which the computer stops administering test questions when it is 95% certain that the test-taker’s ability is clearly above the passing standard or clearly below the passing standard. The second scenario is known as the Maximum-Length Exam, in which the final ability estimate of the test-taker is considered. If the final ability estimate is above the passing standard, the test- taker passes; if it is below the passing standard, the test-taker fails. The third scenario is the Run-Out-Of-Time-Rule (R.O.O.T). If the examination ends because the test-taker ran out of time, the computer may not have enough information with 95% certainty to make a clear pass-or-fail decision. If this is the case, the computer will review the test-taker’s performance during testing. If the test-taker has not answered the minimum number of required questions, the test-taker fails. If the test-taker’s ability estimate was consistently above the passing standard on the last 60 questions, the test-taker passes. If the test-taker’s ability estimate falls to or below the passing standard, even once, the test-taker fails. Additional information about pass or fail decisions can be found in the 2013 NCLEX examination candidate bulletin located at www.ncsbn.org.