1. Maintaining a positive attitude
Pathways to Success
The FOUNDATION
Maintaining a positive attitude
Thinking about short- and long-term realistic goals
Developing control

2. Documenting short- and long term realistic goals
THE LIST
Documenting short- and long term realistic goals
Maintaining control
THE PLAN
Developing a study plan and schedule
Deciding on the place to study
Balancing personal and work obligations with the study schedule
Sharing the study schedule and personal needs with others
Implementing the study plan

3. POSITIVE PAMPERING Establishing healthy eating habits
Planning time for exercise and fun activities
Including activities in the schedule that provide positive mental stimulation

4. Relaxing on the day before the examination
FINAL PREPARATION
Reviewing goals
Identifying goals achieved
Remaining focused to complete the plan of study
Writing down the date and time of the examination and posting it next to your name with the letters R.N following, and the word “YES!”
Planning a test drive to the testing center
Relaxing on the day before the examination

5. Reaching the peak of the Pyramid to Success
THE DAY OF THE EXAMINATION
Grooming yourself for success
Eating a healthy and nutritious breakfast
Maintaining a confident and positive attitude
Maintaining control
Meeting the challenges of the day
Reaching the peak of the Pyramid to Success

6. DEVELOPING A PLAN FOR STUDY
Do I work better alone or in a group study environment?
If I work best in a group, does the group consist of one, two, or more study partners?
Who are these study partners?
How long should my study sessions last?
Does the time of the day that I study make a difference for me?
Do I retain more if I study in the morning?
How does my work schedule affect my study pattern?
How do I balance my family obligations with my need to study?
Do I have a comfortable study area at home or do I need to find an another environment that is conducive to my study needs?

7. TEST- TAKING STRATEGIES

8. PYRAMID TO SUCCESS
Read the question and every option thoroughly and carefully!
Ask yourself, “What is the question specifically asking?”
Be alert to key words and true and false response stems!
Eliminate the incorrect options!
Use all of your nursing knowledge, your clinical experiences, and your test-taking skills and strategies to answer the questions!

9. HOW TO AVOID READING INTO THE QUESTION

10. A. Pyramid points
1. Identify the case situation from the stem of the question
2. Identify what the question is asking
3. Look for the key words
4. Read every option
5. Use the process of elimination
6. As you read the question, avoid asking yourself “What if….?

11. B. The Case Situation
Case Situation: The nurse is monitoring a child for bleeding following surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing.
> The case situation provides you with the information about a clinical health problem and the information that you need to consider in answering the question
> Read all of the information and every word in the case situation

12. C. The Stem of the Question
Stem: Which of the following would be the most appropriate nursing intervention?
1. The Stem of the question follows the case situation and asks something specific about the case situation
2. Read the stem carefully, and specifically identify exactly what is being asked

13. D. The Options
Options:
1. Circle the area of drainage and continue to monitor
2. Reinforce the dressing
3. Notify the physician
4. Document the findings and continue to monitor
> The options are all of the answers, and you must select one
> Read every options to be sure that you understand what is being asked
> Use the process of elimination
> Once you have eliminated two incorrect options, reread the stem of the question again to identify specifically what the question is asking, before selecting the correct option

14. KEY WORDS
A. Key words focus your attention on critical ideas in the case situation, the stem, and the options
Common key words:
Early or late
Best
First
Initial
Immediately
Most likely or Least likely
Most Appropriate or Least Appropriate
On the Day of
After Several Days

15. Key words to Eliminate Incorrect Options
B. Key words are important to identify because they will assist in eliminating the incorrect options
Key words to Eliminate Incorrect Options
Which of the following is an EARLY sign of shock?
Which of the following is a LATE sign of shock?
> ON THE DAY OF surgery, following a transurethral resection of the prostate (TURP), the nurse notes that the client’s urine is bright red in color. Which of the following nursing actions is MOST APPROPRIATE?
AFTER SEVERAL DAYS, following a transurethral resection of the prostate (TURP), the nurse notes that the client’s urine is bright red in color.
Which of the following nursing actions is MOST APPROPRIATE?
Noting the key words in each of these situations will assist in directing you to select the correct option.
The EARLY signs of shock are quite different from the LATE signs of shock!
Bright red urine might be expected ON THE DAY OF surgery following a transurethral resection of the prostate (TURP), but would not be expected AFTER SEVERAL DAYS!

16. THE CLIENT OF THE QUESTION
* Identify the client of the question
* The client is the person who is the focus of the question
* It is important to remember that the client of the question may not be the person with the health problem; in the test question, the client may be a relative, friend, spouse, significant other, or another member of the health care team.
* After identifying the client of the question, select the option that relates to and most directly addresses that client

17. THE ISSUE OF THE QUESTION
Fat emulsion is prescribed for the client receiving total parenteral nutrition (TPN). The nurse is preparing to hang the fat emulsion and notes the presence of fat globules in the solution. The most appropriate nursing action is to:
A. Shake the solution to dissolve the globules
B. Call the physician
C. Return the solution to the pharmacy
D. Place the solution in a bath of warm water until the globules dissolve

18. Answer: C
Test-Taking Strategy: Focus on the issue, the presence of fat globules in the solution. Thinking about the significance of fat globules in the solution and the potential adverse impact of fat globules entering the client’s bloodstream will direct you to the correct option.

19. A. Identify the issue of the question
B. The issue of the question is the specific subject content that the question is asking about
C. Identifying the issue of the question will assist in eliminating the incorrect options and direct you to selecting the correct option
D. The issue of the question can include
1. A medication or intravenous (IV) therapy
2. A side effect of a medication
3. An adverse or toxic effect of a medication
4. A treatment or procedure
5. A complication of a health care problem, treatment, or procedure
6. A specific nursing action

20. TRUE OR FALSE RESPONSE STEMS
A. True response stem
The nurse is reviewing the laboratory results of a client seen in the health care clinic. The nurse notes that the red blood cell count is decreased. The nurse determines that this finding most likely occurs in which of the following conditions?
A. Polycythemia Vera
B. Dehydration
C. Severe Diarrhea
D. Iron deficiency

21. Answer: D
Test-taking Strategy: Note the key words “most likely”. Also, note the relationship between the words “decreased” in the case situation and “deficiency” in the correct option.

22. True response stems use key words that ask you to select an option that is true regarding the case situation in the question
Common key words used in a true response stem
Most or most appropriate
Most likely
Best
Best judgment
Initial
First
Chief
Immediate

23. B. False response stem
The nurse has provided discharge instructions to a client who underwent a right mastectomy with axillary lymph node dissection. Which statement if made by the client indicates a need for further instruction regarding home care measures?
A. “I need to be sure to wear thick mitt covers or use thick pot holders when I am cooking.”
B. “I should inform all of my health care providers that I have had this surgical procedure.”
C. “It is alright to use a straight razor to shave under my arms.”
D. “I need to be sure that I do not have blood pressures or blood drawn from my right arm.”

24. Answer: C
Test-Taking Strategy: Note the key words “need for further instruction.” These key words indicates that you need to select an option that identifies an incorrect client statement. Recalling that edema and infection are the concerns with this client and that the client needs to be instructed in the measures that will avoid trauma to the affected arm will direct you to the correct option.

25. > Need for further instructions or education
* False response stems use key words that ask you to select an option that is NOT true regarding the case situation in the question
* Common key words used in a false response stem
> Except or not
> Least likely
> Need for further instructions or education
> Lowest priority
> Incorrect
> Unsafe

26. QUESTIONS THAT REQUIRE PRIORITIZING
A. Identify the key words in the question that indicate the need to prioritize
B. Common key words
Initial
Essential
Immediate
Highest
Best
Most
Priority

27. C. Use Maslow’s Hierarchy of Needs theory as a guide to prioritize
The nurse is reviewing the plan of care for a pregnant client with a diagnosis of sickle cell anemia. Which nursing diagnosis, if stated on the plan of care, would the nurse select as receiving the highest priority?
A. Anxiety
B. Ineffective individual coping
C. Altered body image
D. Fluid volume deficit

28. Answer: D
Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory to prioritize, remembering that physiological needs come first. Using this guideline will direct you to option 4. Fluid volume deficit is a physiological need and is the priority nursing diagnosis.

29. Physiological needs come FIRST; select an option that addresses a physiological need
2) When a physiological need is not addressed in the question or noted in one of the options, safety needs receive priority; select an option that addresses safety

30. D. ABCs: airway, breathing, and circulation
The client with a diagnosis of cancer is receiving morphine sulfate 10 mg
subcutaneously every 3 to 4 hours for pain. When preparing the plan of
care for the client, the nurse includes which priority action?
A. Monitor the client’s temperature
B. Monitor the urine output
C. Encourage the client to cough and deep breath
D. Encourage increased fluids

31. Answer: C
Teat-Taking Strategy: use the ABCs- airway, breathing, and circulation- as a guide to direct you to the correct option. Recall the morphine sulfate suppresses the cough reflex and the respiratory reflex. The correct option addresses airway.

32. Use the ABCs when selecting an option
2) Remember the order of priority: airway, breathing, and circulation

33. E. Nursing process Steps of the Nursing Process Assessment │ Analysis
Use the nursing process to answer questions!
Analysis │
Follow the steps of the nursing process to select an option
Planning │
The first step of the nursing process is assessment
When the question asks you what the nurse’s initial,
first, or most appropriate action is, select the option
that relates to assessment of the client! │ │
Implementation
Evaluation

34. 1) Guidelines Use the steps of the nursing process to prioritize
Remember that assessment is the first step in the nursing process
When you are asked to select your first and initial nursing action, follow the steps of the nursing process to select the correct option
If an option contains the concept of assessment or the collection of client data, select that option

35. 2) Assessment
The nurse is teaching a client with diabetes mellitus about dietary measures to follow. The client expresses frustration in learning the dietary regimen. The nurse would initially:
A. Identify the cause of the frustration
B. Continue with the dietary teaching
C. Notify the physician
D. Tell the client that the diet needs to be followed

36. Answer: A
Test-Taking Strategy: Use the steps of the nursing process. Assessment is the first step. Of the four options presented, the only assessment option is option 1. Options 2,3 and 4 identify the implementation step of the nursing process. The initial action is to identify the cause of the frustration.

37. Assessment questions address the process of gathering subjective and objective data relative to the client, confirming that data, and communicating and documenting the data
2) Remember that assessment is the first step in the nursing process
3) When you are asked a question regarding your initial or first nursing action, select the option that addresses an assessment action
4) If an assessment action is not one of the options, follow the steps of the nursing process as your guide to select your initial or first action
5) When answering questions that focus on assessment, look for key in the options that reflect assessment

38. Key Words: Ascertain Assess Check Determine Find out Identify Monitor
Observe
Obtain information

39. 3) Analysis
The nurse is reviewing the laboratory results of a client with a diagnosis of leukemia. The nurse notes that the granulocyte count is decreased. The nurse interprets that the client is at risk for:
A. Infection
B. Bleeding
C. Anemia
D. Dehydration

40. Answer: A
Test-Taking Strategy: It is necessary to understand the physiology associated with leukemia and the effects of a decreased granulocyte count to answer this question correctly. Analysis of this information will direct you to the correct option.

41. Analysis questions are the most difficult questions because they require understanding of the principles of physiological responses and require interpretation of the data on the basis of assessment
2) Analysis questions require critical thinking and determining the rationale for therapeutic interventions that may be addressed in the case situation
3) Analysis questions may address the formulation of a nursing diagnosis and the communication and documentation of the results of the process of analysis

42. 4) Planning
The nurse is preparing to care for a client following a gastroscopy procedure. The nurse includes which most appropriate intervention in the nursing care plan?
A. Place the client in a supine position to provide comfort
B. Monitor the client’s vital signs every hour for 4 hours
C. Provide saline gargles immediately upon return to the unit to aid in comfort
D. Check the gag reflex by using a tongue depressor to stroke the back of client’s
throat.

43. Answer: D
Test-Taking Strategy: Planning questions include developing the plan of care and determining goals and outcome criteria for goals of care. Use of the ABCs- airways, breathing and circulation- will also assist in answering this question. Option 4 is the only option that addresses airway.

44. Planning questions require prioritizing nursing diagnoses, determining goals and outcome criteria for goals of care, developing the plan of care, and communicating and documenting the plan of care
2) Remember that this is a NURSING examination and the answer to the question most likely involves something that is included in the nursing care plan, rather than the medical plan.

45. 5) Implementation
The emergency room nurse is caring for a child suspected of epiglottitis. The nurse has ensured that the child has a patent airway. The next priority intervention in the care of this child would be to:
A. Prepare the child for a chest x-ray
B. Assist the physician with intubation
C. Prepare the child for tracheostomy
D. Prepare to administer epinephrine

46. Answer: A
Test-Taking Strategy: Implementation questions address the process of organizing and managing care. This question also requires that you prioritize the nursing actions. When epiglottitis is suspected, the priorities are to maintain a patent airway and to obtain a chest x-ray to confirm the diagnosis. If epiglottitis is present, the child is taken promptly to the operating room for tracheal intubation or immediate surgical airway. Epinephrine is not used in the treatment of epiglottitis.

47. This exam is about nursing, so focus on the nursing action rather than on the medical action; unless the question is asking you what prescribed medical action is anticipated.
2) Implementation questions address the process of organizing and managing care, counseling and teaching, providing care to achieve established goals, supervising and coordinating care, and communicating and documenting nursing interventions
3) On NLE, the only client whom you need to be concerned about is the client in the question that you are answering
4) When you are answering a question, remember that this client is your only assigned client
5) Answer the question as if the situation were textbook and ideal and the nurse had all the time and resources needed and readily available at the client’s bedside

48. B. “Our child sleeps in our bedroom at night.”
6) Evaluation
The nurse is performing an admission assessment on a child with a seizure disorder. The nurse is interviewing the child’s parents to determine their adjustment to caring for their child, who has a chronic illness. Which statement if made by a parent of the child would indicate a need for further teaching?
A. “Our child is involved in a swim program with neighbors and friends.”
B. “Our child sleeps in our bedroom at night.”
C. “Our baby-sitter just completed cardiopulmonary resuscitation (CPR) training.”
D. “We worry about injuries when our child has a seizure.”

49. Answer: B
Test-Taking Strategy: This is an evaluation question and contains a false response stem as identified by the words “need for further teaching.” Option 2 identifies a need to provide the parents with an alternate method to monitor for a night seizures. Options 1 and 3 identify parental understanding of the disorder. Option 4 is a common concern.

50. Evaluation questions focus on comparing the actual outcomes of care with the expected outcomes
2) Evaluation questions address evaluating the client’s ability to implement self-care, health care team member’s ability to implement care, and the process of communicating and documenting evaluation findings
3) Evaluation questions also focus on how the nurse should monitor or make a judgment concerning a client’s response to therapy or to a nursing action
4) In an evaluation question, be alert to false response stems because they are frequently used in evaluation-type questions, and the question may ask for a client statement that indicates either accurate or inaccurate information related to the issue of the question

51. * Communications questions
Psychosocial Alterations
* These questions address the provision that the nurse provides nursing care that supports and promotes the emotional, mental, and social well- being of the client and significant other(s)
* Content addressed in these questions relates to promoting the client or significant other’s ability to cope, adapt, or problem solve in situations such as illness or stressful events, and providing care to clients with maladaptive behavior or acute or chronic mental illness
* Communications questions

52. TOOLS
BLOCKS
Being Silent
Giving advice
Offering self for assistance
Showing approval/ disapproval
Showing empathy
Using clichés and false reassurance
Focusing
Requesting an explanation “Why”
Restatement
Devaluing client feelings
Validation/clarification
Being defensive
Giving information
Focusing on inappropriate issues or persons
Dealing with the here and now
Placing the client’s issues on “hold”

53. Always focus on the client’s feeling FIRST!
If an answer reflects the client’s feelings, select that answer!
Identify the use of therapeutic communication tools
b. Use of communication tools indicates a CORRECT option
c. Use of communication blocks indicates an INCORRECT option
d. Always focus on the client’s feelings first; if an option reflects the client’s feelings, select that option as the answer to the question

54. Focusing on the Client’s Feelings
The nurse in the mental health unit is having a conversation with a client diagnosed with post-traumatic stress disorder. The client seems upset and seems to be having difficulty with realistic behavior. The most appropriate nursing response to the client is which of the following?
A. “Don’t worry so much.”
B. “Everything is going to be all right.”
C. “I can see that you are upset about this. Why don’t we talk about it?”
D. “Why are you having so much trouble controlling your anxiety?”

55. Answer: C
Test-Taking Strategy: Option 3 is the only option that addresses the client’s feelings and concerns. Options 1 and 2 provide false reassurance and place the client’s feelings on hold. Option 4 is a nontherapeutic communication technique and will increase the client’s anxiety.

56. PYRAMID POINTS
* If the question asks for an immediate action or response, all options may be correct; therefore, base your selection on priorities
* Reword a difficult question, but if you do so, be careful not to change the intent of the question
* Relate the situation to something that you are familiar with and try to visualize the client as you go through the case situation and the question
* If there are words in the case situation or stem of the question that are unfamiliar, try to figure out the meaning in terms of the context of the sentence or break down the word and use medical terminology skills

57. * If one option includes qualifiers such as GENERALLY, USUALLY, TENDS TO, POSSIBLY, or MAY, and other options do not, select that option
* Absolute terminology such as ALWAYS, NEVER, ALL, EVERY, NONE, MUST, and ONLY tend to make an option incorrect
* With medication calculations, talk yourself through each step and be sure the answer make sense; recheck the calculation before selecting an option, particularly if the answer seems like an unusual dosage
* Remember, the only client you need to be concerned about is the one in the question you are answering, and answer the question as if the situation were ideal and the nurse had all the time and resources readily available at the client’s bedside

58. Pace yourself, concentrate, and focus on one item at a time; if you find yourself becoming distracted, take a few minutes to breathe deeply and then refocus
SMILE!
BELIEVE!
CONFIDENCE!
CONTROL!
SUCCESS!

59. A. Unfamiliar content
* Answer questions by using your nursing knowledge, clinical experiences, and test-taking skills and strategies
* If the content of a question is unfamiliar and you are unable to answer the question by using your nursing knowledge, look for a global option, similar distracters, or similar words, behaviors, thoughts, or feelings in the question and in one of the options

60. B. Global option
The nurse in the emergency room receives a telephone call from emergency medical services and is told that several victims who survived a plane crash will be transported to the hospital. The nurse is told that several victims are suffering from cold exposure because the plane plummeted and submerged into the local river. The initial nursing action of the emergency room nurse is which of the following?
A. Supply the triage rooms with bottles of sterile water and normal saline
B. Call the laundry department and ask the department to send as many warm blankets as possible to the emergency room
C. Call the nursing supervisor to activate the agency disaster plan
D. Call the intensive care unit to request that nurses be sent to the emergency room

61. Answer: C
Test-Taking Strategy: Option C is the global option. Activating the agency disaster plan will ensure that the interventions in options A,B and D will occur.
1). When more than one option appears to be correct, look for a global option
2). A global option is one that is a general statement and may include the ideas of the other options within it

62. 4. The answer to the question is the option that is different
C. Similar distracters
1. If you don’t know the answer, try looking for similar distracters
2. Remember that there is only ONE correct option
3. If two options say the same thing or include the same idea, then NEITHER OF THESE OPTIONS can be correct
4. The answer to the question is the option that is different

63. D. Similar words, behaviors, thoughts, or feelings
1. If you do not know the answer, look for a similar word, behavior, thought, or feeling used in the case situation or the stem of the question and in one of the options
2. If you find a word, behavior, thought, or feeling that is used in the case situation or the stem of the question and is repeated in one of the options, that option MAY be the correct one

64. E. Pharmacology questions
* If you are familiar with the medication, use nursing knowledge to answer the question
* Remember that the question will identify both the generic name and the trade name of the medication
* If the case situation identifies a diagnosis, then you can make a relationship between the medication and the diagnosis; for example, you can determine that cyclophosphamide (Cytoxan) is an antineoplastic medication if the question refers to a client with a breast cancer who is taking this particular medication

65. * Try to determine the classification of the medication being addressed to assist in answering the question; identifying the classification will assist in determining a medication action and/or side effects (Cardiazem is a cardiac medication)
* Use medical terminology, and break the name of the medication into parts; for examples, Lopressor can be broken down into Lo and pressor, meaning lowering the blood pressure.
* Look at the prefix and/or suffix of the medication name; “ase” indicates an enzyme, “sone” indicates a steroid; “line” indicates a bronchodilator, and “lol” indicates a beta-blocker

66. * General principles to remember
A. Clients are instructed to avoid alcohol with medications
B. Capsules and sustained- released medications are not to be crushed
C. The nurse never adjusts or changes the client’s medication dosage and never discontinues a medication
D. Medications are never administered if the order is difficult to read, is unclear, or identifies a medication dose that is not a normal one