The NCLEX-RN® Exam Versus Real-World Nursing

Some of you are LPNs or LVNs completing your RN studies, while others are EMTs. Some of you worked during school as student techs. All of you, however, spent time in a clinical setting during your nursing education. All of this adds up to a significant amount of experience. Experience will help you get a job, but answering questions based on your experience can be dangerous on the NCLEX-RN® exam.

Look at the following question.

1. On admission to the hospital, an elderly client appears disheveled and is restless and confused. During the client’s second day on the unit, a nurse approaches the client to administer medication. The nurse is unable to identify the client because his armband is missing. Which of the following actions by the nurse is the BEST?
   1. Have the client’s roommate identify him.
   2. Ask the client to state his full name.
   3. Ask another nurse to identify the client.
   4. Look in the chart at the picture of the client.

Let’s see how someone using his or her real-world experience would approach this question:

1. “The roommate is never involved in identification of a client.”
2. “A confused client cannot be relied on for an accurate identification.”
3. “Sounds reasonable. I have seen this done in some circumstances.”
4. “A picture? What picture? I’ve never seen a picture of a client in a chart!”

Possible conclusions drawn by this person would include: “OK, I’ve seen one nurse ask another for information so (3) must be the answer,” or “Well, maybe the client isn’t all that confused, so I’ll select (2).”

According to nursing textbooks, asking another health care professional is not the correct way to identify a client. Many acute-care settings now include a photo of the client in the chart for just this type of situation. The correct answer to this question is (4). Many students reject this answer because there are rarely pictures of clients in the charts. Real-world experience doesn’t count, though; in this case, the client does have a picture in his chart.

The NCLEX-RN® exam is a standardized exam administered by NCSBN. Because the NCLEX-RN® exam is a national exam, students should be aware that in some parts of the country, nursing is practiced slightly differently. However, to ensure that the test is reflective of national trends, questions and answers are all carefully documented. The test makers ensure that the correct answers are documented in at least two standard nursing textbooks, or in one textbook and one nursing journal.

When you are unsure of an answer choice, don’t ask yourself, “What do they do on my floor?” but “What does the medical/surgical textbook writer Brunner say?” or “What do Potter and Perry say to do?” This test does not necessarily reflect what happens in the real world, but is based on textbook nursing.

Remember the following when taking the NCLEX-RN® exam:

• You have all of the time and resources you need to provide appropriate care to your client. (Checking for bowel sounds for five minutes in all four quadrants, no problem!)
• You have all of the equipment you need. (Remember the bath thermometer you learned to use in the nursing lab? For the NCLEX-RN® exam, you will have one available to test the temperature of bath water.)
• There are no staffing problems on the NCLEX-RN® exam. You are caring only for the client described in the question, and that person is your only concern.
• All care given to clients is “by the book.” No shortcuts are used. (You would not turn off an IV solution, flush the line, give another IV solution, flush the line, and then restart the original IV solution that was ordered to be run continuously.)

Answer the following question.

1. A client is treated in the emergency room for acute alcohol intoxication. He has a five-year history of alcohol abuse. He is agitated and verbally abusive. His admission orders include chlordiazepoxide 50 mg IM or PO every 4–6 hours for agitation. The nurse should take which of the following precautions after chlordiazepoxide is administered?
   1. Place the client in restraints.
   2. Leave the client in a room by himself until the tranquilizer takes effect.
   3. Assign a practical nurse to stay with the client and document his condition.
   4. Ask the security guard to stay with the client.

Let’s look at this using real-world logic.

1. “Place the client in restraints.” Yes, that is done in the real world.
2. “Leave the client in a room by himself until the tranquilizer takes effect.” Yes, that is done in the real world, but most students recognize that it is not the best answer.
3. “Assign a practical nurse to stay with the client and document his condition.” Sounds good, but what if you don’t have enough staffing to assign an LPN/LVN to sit with this client?
4. “Ask the security guard to stay with the client.” Yes, in the real world, security is called when clients are agitated.

According to real-world logic, the correct answer must be (1) or (4). However, textbook theoretical nursing practice states that this client should not be left alone while in an agitated state. A professional should remain with the client. Therefore, the correct answer is (3).

Use your real-world experience to help you visualize the client described in the test question, but select your answers based on what is found in nursing textbooks.

Your nursing faculty has probably been conscientious about instructing you in the most up-to-date nursing practice. According to the National Council, the primary source for documenting correct answers is in nursing textbooks, and the most up-to-date practice might not always agree with the textbooks. When in doubt, always select the textbook answer!

The next question illustrates this point.

1. A woman is admitted to the hospital and delivers a healthy 7 lb., 2 oz. girl. The mother decides to bottle-feed her infant. Which of the following statements by the mother after a teaching session indicates to the nurse that the client needs further instruction?
   1. “I’ll pump my breasts and use warm packs to relieve breast pain.”
   2. “I’ll use a tight bra and ice packs to relieve engorgement discomfort.”
   3. “I’ll take the medication prescribed by the doctor for pain.”
   4. “I’ll take the pills ordered by my doctor to help stop the production of milk.”

Let’s look at these answers more closely.

1. Pumping the breasts will stimulate milk production. This is clearly wrong.
2. Wearing a tight bra and using ice packs are appropriate interventions for a nonbreastfeeding mother.
3. Taking a medication (mild analgesic) is an appropriate intervention for a nonbreastfeeding mother.
4. Medication to prevent lactation is not frequently prescribed because of potentially dangerous side effects. However, a medication may be prescribed to prevent lactation. This would be considered an appropriate intervention.

The correct answer is (1).

First Take Care of the Client, Then the Equipment

The NCLEX-RN® exam tests your ability to use critical thinking skills to make nursing judgments. It is very important that you remember to:

• Take care of the client first.
• Take care of the equipment second.

Look at the following question.

1. A client sustains a fractured left femur in a car accident. She is placed in balanced suspension skeletal traction using a Thomas splint and a Pearson attachment. The client tells the nurse that she has “terrible” pain in her left thigh. Which of the following should the nurse do FIRST?
   1. Determine that all the weights and ropes from the traction apparatus are in line and hanging free.
   2. Ask the client for more information about the location and characteristics of her pain.
   3. Check the Thomas splint and Pearson attachment to make sure they are appropriately positioned.
   4. Explain to the client that the pain she is experiencing in the affected leg is a common occurrence.

Let’s review the answers:

1. All weights should be hanging free in balanced suspension skeletal traction. This answer choice has you checking the equipment, not the client. Your first concern should be the client, not the traction.
2. The nurse should focus on assessing the client and her problem before assessing the function of the equipment. All reports of pain should be thoroughly investigated by the nurse.
3. This answer choice has you checking the equipment, not the client. Your first concern should be the client, not the traction.
4. Any reports of pain are considered abnormal, and you should investigate them thoroughly.

The correct answer is (2).

Laboratory Values

Answering questions about lab values is another example of how the real world does not work on the NCLEX-RN® exam. In nursing school, you learned lab values for a specific test and you may not have remembered them after the test. While you were in the clinical setting, the emphasis was on interpretation of lab values. Because most lab slips contained a listing of normal values, you were able to compare the client’s results to the normal levels. Questions on the NCLEX-RN® exam will not provide you with a listing of normal lab values.

To answer questions on the NCLEX-RN® exam, you must:

• Know normal lab test results.
• Correctly interpret normal or abnormal lab test results.

Compare the following two questions.

1. A client is admitted to the hospital with flu-like symptoms. When taking the history, the nurse learns that the client has been taking digoxin 0.125 mg PO daily and furosemide 40 mg PO daily for 3 years. Last month her physician changed the prescription for digoxin to 0.25 mg qd. The nurse would expect the physician to order which of the following laboratory tests?
   1. Serum electrolytes and digoxin level
   2. White blood cell count, hemoglobin, and hematocrit
   3. Cardiac enzymes and an arterial blood gas
   4. Blood cultures and urinalysis

You are probably familiar with the concepts presented in this question. The physician has increased the client’s dose of digoxin. Furosemide (Lasix) is a loop diuretic that inhibits resorption of sodium and chloride; side effects include hypotension, hypokalemia, GI upset, and weakness. Hypokalemia may increase the client’s risk of digitalis toxicity. Serum electrolytes and digoxin level (1) is the correct answer.

Now look at this question.

1. The nurse plans care for a teenager admitted with fever, vomiting, and diarrhea. The nurse writes the following nursing diagnosis on the client’s care plan: “fluid volume deficit.” Which of the following changes in laboratory values would demonstrate an improvement in the client’s condition?
   1. Urine specific gravity, 1.015; hematocrit, 37%
   2. Urine specific gravity, 1.020; hematocrit, 45%
   3. Urine specific gravity, 1.032; hematocrit, 52%
   4. Urine specific gravity, 1.025; hematocrit, 35%

In order to correctly answer this question, you must know:

• The specific gravity of urine (1.010–1.030) and the normal levels of hematocrit (male 42–50%, female 40–48%)
• How the specific gravity and hematocrit levels are affected by a fluid volume deficit

Fluid volume deficit occurs when water and electrolytes are lost in the same proportion as they exist in the body. When a client is dehydrated, both the specific gravity of urine and the hematocrit become elevated. The correct answer is (2).

Answer the following question.

1. A client is hospitalized with a diagnosis of atrial fibrillation. Heparin 5,000 units is ordered every 12 hours to be given subcutaneously. The health care provider orders daily partial thromboplastin times (PTT). The result of the client’s most recent PTT is 55. Which of the following actions should be taken by the nurse?
   1. Document the results and administer the heparin.
   2. Withhold the heparin.
   3. Notify the health care provider.
   4. Have the test repeated.

In order to answer this question you need to know:

• The normal range for a PTT is 20–45 seconds.
• The therapeutic range for a client receiving heparin, an anticoagulant, is 1.5–2 times the control or normal level.
• To calculate the therapeutic range, take the lower number for the normal range for a PTT (20) and multiply it by 1.5. The result is 30. Multiply the higher number (45) by 2. The result is 90. Any result that falls within 30 to 90 seconds is considered therapeutic. The goal is to keep the PTT within this range.

Evaluate the answer choices:

1. “Document the results and administer the heparin.” The client’s most recent PTT is 55. This is within the therapeutic range of 30 to 90, so the nurse should administer the medication.
2. “Withhold the heparin.” A side effect of heparin is bleeding. If the clotting time is greater than 90 seconds, the nurse should notify the health care provider.
3. “Notify the health care provider.” There is no reason to notify the health care provider, since the PTT is within the therapeutic range.
4. “Have the test repeated.” There is no reason to have the test repeated.

The correct answer is (1).

Medication Administration

An important function in providing safe and effective care to clients is the administration of medications. Because this is one of the responsibilities of a beginning practitioner, questions about medications are often an important part of the NCLEX-RN® exam. The nurse who is minimally competent is knowledgeable about medications and uses the “six rights” when administering medication.

In nursing school, most questions about medication followed the same pattern. You were told the client’s diagnosis and the name of the medication, and then were asked a question. Even if you didn’t know the information about the medication, sometimes you were able to select the correct answer by knowing the diagnosis.

The NCLEX-RN® exam does not give you any clues from the context of the question. The questions on this exam include the name of the medication, generally identifying it by generic name only. Most of the time, you will not be given the reason the client is receiving the medication.

Let’s look at some medication questions.

1. The physician orders furosemide and spironolactone for a client. Prior to administering the medication, the nurse determines that the client’s potassium is 3.2 mEq/L. In addition to notifying the physician, the nurse should anticipate taking which of the following actions?
   1. Do not administer the furosemide or spironolactone.
   2. Administer the spironolactone only.
   3. Administer the furosemide only.
   4. Administer the furosemide and spironolactone.

This is a typical exam-style medication question. The question concerns the side effects and nursing implications of furosemide and spironolactone.

1. The potassium level is below normal (3.5–5.0 mEq/L). Furosemide is a potassium-wasting diuretic. spironolactone is a potassium-sparing diuretic. There is no reason to hold the spironolactone because the client has a low potassium level. Eliminate this answer.
2. The spironolactone should be administered.
3. Do not administer the furosemide because it is a potassium-wasting diuretic. The client’s potassium level is already low. Eliminate.
4. Do not administer the furosemide. Eliminate.

The correct answer is (2).

Let’s try this next question.

1. A client returns to the clinic 2 weeks after being started on allopurinol 200 mg PO daily. The nurse reviews information about this medication with the client. Which of the following statements by the client indicates that the teaching was effective?
   1. “I should take my medication on an empty stomach.”
   2. “I should take my medication with orange juice.”
   3. “I should increase my intake of protein.”
   4. “I should drink at least 8 glasses of water every day.”

To answer this question you need to know information about allopurinol, an antigout agent that reduces uric acid.

1. Allopurinol is best tolerated with or immediately after meals to reduce gastrointestinal (GI) irritation. Eliminate.
2. Orange juice makes the urine acidic. Allopurinol is more soluble in alkaline urine. Eliminate.
3. It is not necessary to increase the intake of protein when taking allopurinol. Eliminate.
4. Allopurinol can cause renal calculi. The client should drink 3,000 mL/day to reduce the risk of kidney stone formation.

The correct answer is (4). You must know the side effects and nursing implications of medications for the NCLEX-RN® exam.

Notify the Physician

Another behavior that commonly occurs in the real world is calling the physician. In nursing school you were encouraged to notify your instructor of changes in your client’s condition. Be very careful how you handle this on the NCLEX-RN® exam. More often than not, the answer choice that states “call the physician,” “contact the social worker,” or “refer to the chaplain” is the WRONG answer. Usually there is something you need to do first before you make that call. The NCLEX-RN® exam does not want to know what the physician is going to do. The NCLEX-RN® exam wants to know what you, the registered professional nurse, will do in a given situation.

Answer this question.

1. A client is receiving packed red blood cells. Several minutes after the infusion is started, the client reports itching and develops hives on his chest and abdomen. Which of the following actions should the nurse take FIRST?
   1. Slow the rate of the transfusion.
   2. Call the physician for an order for an antihistamine.
   3. Mix IV fluid with the blood to dilute it.
   4. Stop the transfusion.

THE REWORDED QUESTION: What should you do first for this client?

It sounds like the client is having an allergic reaction to the transfusion. If this is what’s going on, what should you do?

1. If the client is having a transfusion reaction, slowing the rate of the transfusion is not the right action.
2. Antihistamines are given for allergic reactions. The doctor needs to be notified. This answer might be a possibility, but is there something you should do first?
3. Mixing IV fluids with blood is done to decrease the viscosity of RBCs. This doesn’t have anything to do with an allergic transfusion reaction. Eliminate.
4. If the client was having a transfusion reaction, the best action is to stop the transfusion. This is the correct action to take first, before the physician is called.

The correct answer is (4). After the transfusion is stopped, you will contact the physician and antihistamines will probably be ordered.

Before you want to choose the answer choice that involves “call the physician,” look at the other answer choices very carefully. Make sure that there isn’t an answer that contains an assessment or action you should do before making the phone call. The test makers want to know what you would do in a situation, not what the doctor would do!

Here is one more real-world question.

1. Upon returning from lunch, the nurse is approached in the elevator by a hospital employee from another unit. The employee states that her close friend is a client on the nurse’s unit. The employee asks how her friend is doing and if all of her tests were normal. The nurse should do which of the following?
   1. Answer the employee’s questions softly so other people on the elevator will not hear.
   2. Refuse to discuss her friend’s medical condition. Suggest that she visit her friend.
   3. Give the employee the name of the client’s physician to call for this information.
   4. Tell the employee about the results of the client’s tests because they were within normal limits.

THE REWORDED QUESTION: What should a nurse do when asked about a client by a hospital employee?

1. Discussing client information in a public place is a breach of confidentiality. Eliminate.
2. Refusing to discuss a client’s medical condition does not violate the client’s right to privacy and confidentiality. Keep in consideration.
3. Providing any information about a client to someone not directly involved in the client’s care is a breach of privacy. Eliminate.
4. It is a breach in the client’s right to privacy to share information with others without the client’s permission. Eliminate.

The correct answer is (2).

Expect to see real-world situations on your NCLEX-RN® exam, but make sure that you do not choose real-world answers! These strategies should help you use your previous nursing experience without encountering any pitfalls.