Chapter 4

The NCLEX-PN^® Exam Versus Real-World Nursing

Some of you are CNAs or other nursing assistive personnel (NAPs) completing your practical/vocational nursing studies, while others are EMTs. Some of you worked during school as student techs. All of you, however, spent time in clinical during your practical/vocational nursing education. All of this adds up to a lot of experience. Experience will help you get a job, but answering questions based on your experience can be dangerous on the NCLEX-PN^® 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, an LPN/LVN approaches the client to administer medication. The LPN/LVN 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 LPN/LVN 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 LPN/LVN 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-PN^® exam is a standardized exam administered by the NCSBN. Because the NCLEX-PN^® exam is a national exam, students should be aware that in some parts of the country, practical/vocational 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 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-PN^® exam:

• You have all of the time and resources you need to provide appropriate care to your client. (Checking for bowel sounds for 5 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-PN^® exam, you will have one available to test the temperature of bath water.)
• There are no staffing problems on the NCLEX-PN^® 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.

Answer the following question.

1. The LPN/LVN prepares an agitated and confused elderly client for surgery. The physician has ordered morphine sulfate 5 mg IM and lorazepam 0.5 mg IM as preoperative medications. The LPN/LVN administers these medications at the appropriate time. The LPN/LVN should take which of the following precautions after the preoperative medication is administered?
   1. Ask the security guard to stay with the client.
   2. Assign nursing assistive personnel (NAP) to stay at the client’s bedside.
   3. Leave the client in his room alone with the side rails up.
   4. Place the client in a vest restraint and dim the room lights.

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

1. Ask the security guard to stay with the client. Yes, in the real world, security is called when clients are agitated.
2. Assign an NAP to stay with the client. Sounds good, but what if you don’t have enough staffing to assign an NAP to sit with the client?
3. Leave the client in his room alone with the bedside rails up. Yes, that is done in the real world for most medicated preoperative clients, but this client is agitated and confused. This is not the best answer.
4. Place the client in a vest restraint and dim the lights. Yes, this is done in the real world.

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 member of the health care staff should remain with the client. Therefore, the correct answer is (2).

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 been very conscientious about instructing you in the most up-to-date nursing practice. According to the National Council of State Boards of Nursing, 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 LPN/LVN 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 non-breastfeeding mother.
3. Taking a medication (mild analgesic) is an appropriate intervention for a non-breastfeeding 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).