Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items (2022)
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Strategies for Student Success on the NEXT GENERATION NCLEX ® ( NGN ) TEST ITEMS
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Linda Anne Silvestri, PhD, RN, FAAN Nursing Instructor University of Nevada, Las Vegas Las Vegas, Nevada; President Nursing Reviews, Inc. and Professional Nursing Seminars, Inc. Henderson, Nevada; Next Generation NCLEX® (NGN) Consultant and Subject Matter Expert Elsevier Inc. Angela Elizabeth Silvestri, PhD, APRN, FNP-BC, CNE Associate Professor and BSN Program Director University of Nevada, Las Vegas Las Vegas, Nevada; President Nurse Prep, LLC Henderson, Nevada; Next Generation NCLEX® (NGN) Subject Matter Expert Elsevier Inc. Donna D. Ignatavicius, MS, RN, CNE, CNEcl, ANEF, FAADN Speaker and Curriculum Consultant for Academic Nursing Programs Founder Boot Camp for Nurse Educators; President DI Associates, Inc. Littleton, Colorado; Next Generation NCLEX® (NGN) Consultant and Subject Matter Expert Elsevier Inc. Strategies for Student Success on the NEXT GENERATION NCLEX ® ( NGN ) TEST ITEMS
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Elsevier 3251 Riverport Lane St. Louis, Missouri 63043 STRATEGIES FOR STUDENT SUCCESS ON THE NEXT GENERATION NCLEX® (NGN) TEST ITEMS ISBN: 978-0-323-87229-4 Copyright © 2023 by Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verication of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. International Standard Book Number: 978-0-323-87229-4 Content Strategist: Heather D. Bays-Petrovic Content Development Manager: Ellen M. Wurm-Cutter Content Development Specialist: Laura Klein; Meredith Madeira Publishing Services Manager: Julie Eddy Senior Project Manager: Jodi Willard Design Direction: Amy Buxton Printed in India Last digit is the print number: 9 8 7 6 5 4 3 2 1
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In loving memory of my parents and Angela’s grandparents, Arnold Lawrence and Frances Mary, who opened my door of opportunity to this amazing profession of nursing. My memories of their love, support, and words of encouragement will remain in my heart forever! And, to my husband, Larry, for being my rock of support through all of my life’s journeys. Linda Anne Silvestri To my husband, Brent, who has supported my work since the day we met. I will always remember how he anticipated what I would need to be successful in this journey. To nursing students, you have chosen a wonderful profession that will give back to you what you are putting in now. You can do this! Angela Elizabeth Silvestri To my family, who has supported my work as an author and consultant for many decades. To nursing students, who have chosen the caring profession that can change the lives of so many, and to nurse educators, whose passion and role modeling continues to shape the future of the nursing profession. Donna D. Ignatavicius
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vi Linda Anne Silvestri, PhD, RN, FAAN Linda is a well-known nurse educator, entrepreneur, and philanthropist whose profes- sional aspirations focus on assisting nursing students to become successful. She has been teaching nursing stu- dents at all levels of nursing education for many years. Dr. Silvestri is currently a nursing instructor at the Uni- versity of Nevada, Las Vegas (UNLV). She earned her PhD in Nursing from UNLV and conducted research on self-ecacy and the predictors of NCLEX® success. Her research ndings are published in the Journal of Nursing Education and Practice. Dr. Silvestri has received several awards and honors. In 2019 she was inducted as a Fellow in the American Academy of Nursing. In 2012 she received the UNLV School of Nursing Alumna of the Year Award. In 2010 she received the School of Nursing Certicate of Recognition for the Outstanding PhD Student. Dr. Silves- tri is a member of several national nursing organizations, some of which include the Honor Society of Nursing, Sigma eta Tau International, the National League for Nursing, the American Nurses Association, and the American Acad- emy of Nursing. Dr. Silvestri is a successful Elsevier author of numerous best-selling NCLEX® preparation resources on national and international levels. She also serves as an Elsevier Consultant and Subject Matter Expert for the Next Generation NCLEX® (NGN) and has presented numerous webinars on NCLEX® preparation and success. Dr. Silvestri is the President and Owner of Nursing Reviews, Inc. and Professional Nursing Seminars, Inc. Both companies are dedicated to helping nursing graduates achieve their goals of becoming licensed nurses. Angela E. Silvestri, PhD, APRN, FNP-BC, CNE Angela Silvestri is a well-known nurse educator, researcher, and author. She has been teaching and working in university administra- tive roles for the last 10 years at all levels of nursing education. She has experience teaching across the program and in both classroom and clinical settings and working with graduate students on their culminating projects and research dissertations. She is cur- rently serving in a leadership role as the Program Director for the undergraduate BSN program at the University of Nevada, Las Vegas (UNLV). Angela earned a bachelor’s in Nursing and in Sociology from Salve Regina University in Newport, RI, and her master’s—with a focus in nursing education—and PhD from the University of Nevada, Las Vegas. She also has a post-master’s graduate certicate in Advanced Practice and is a board-certied Family Nurse Practitioner. She is a Scholar in Sigma eta Tau’s New Academic Leadership Academy. Angela is passionate about college student success. She works as a Family Nurse Practitioner with faculty, sta, and stu- dents on managing primary and episodic health care needs at UNLV’s Student Wellness Center and Faculty and Sta Treatment Center. Dr. Silvestri is a successful Elsevier author of numerous best-selling NCLEX® preparation resources on national and international levels. She also serves as an Else- vier Subject Matter Expert for the Next Generation NCLEX® (NGN). is passion also comes through in her work at the School of Nursing teaching leadership and licensure exam preparation, as well as in publishing research and best-selling licensure exam review resources on national and international levels. Donna D. Ignatavicius, MS, RN, CNE, CNEcl, ANEF, FAADN Nationally recognized as an expert in nursing education and medical-surgical nurs- ing, Donna, better known as “Iggy,” has a wealth of expe- rience in education, clinical nursing, and administra- tion. rough her company, DI Associates, Inc., Iggy speaks at national and state conferences and provides consultation on such topics as curriculum transformation and NGN prep- aration. In addition, she is the author of a number of articles, chapters, and books, including the tenth edition of her lead- ing textbook, Medical-Surgical Nursing: Concepts for Interpro- fessional Collaborative Care . In 2007 Iggy was inducted as a fellow into the very prestigious Academy of Nursing Educa- tion for her national contributions to nursing education. In 2021 she was also inducted as a fellow into the Academy of Associate Degree Nursing for her national inuence and con- tributions to programs preparing students for nursing prac- tice. Iggy obtained her Certied Nurse Educator® credential in 2016 and her Certied Academic Clinical Educator® cre- dential in 2020. About the Authors
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vii We want to acknowledge the many people from Elsevier who were such a signicant part of our journey as we prepared this resource for nursing students. First and foremost, we extend our deepest appreciation to Heather Bays-Petrovic, Content Strategist, for accepting our proposal and promot- ing our vision for this project and for supporting us every step of the way from start to nish. ank you, Heather! Jodi Willard, Senior Project Manager, has been instrumental in moving this publication forward. Jodi’s work and attention to detail has been signicant in the design and nal prod- uct. ank you, Jodi! We also extend our sincere gratitude to Laura Klein, Senior Content Development Specialist; Amy Buxton, Senior Book Designer; and Julie Eddy, Publishing Services Manager. We thank all of you for your willingness and exibility to design this resource ensuring that our ideas and vision were executed and for your consistent attention to the many details in our manuscript. Finally, we want to thank Bruce Seibert, Senior Digital Media Producer, and Bala Cherukumilli, Digital Media Producer, for all of your patience and assistance in implementing our requests for the electronic platform that accompanies this resource. A very grateful and appreciative “ank You” from us to all of you— we could not have achieved our aspirations for this resource without you! Acknowledgments
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viii Welcome to the Strategies for Student Success on the Next Gen- eration NCLEX® (NGN) Test Items! is book is focused on providing you with information about the Next Generation NCLEX® (NGN) and practice questions to prepare you to successfully answer the new test item types expected on the NGN. a is book highlights gen- eral NGN Tips and unique test-taking strategies. Chapter 1 introduces the clinical judgment (CJ) cognitive skills upon which the new test items will be based. Chapter 2 presents examples of the new NGN test item types. Chapters 3 through 8 describe the CJ cognitive skills and present unique test- taking strategies on how to answer practice items that measure each skill. Chapter 9 demonstrates how Stand-alone items and Unfolding Case Studies will be presented on the NGN, and Chapter provides an NGN Practice Test to apply what was learned throughout the book. e answers, rationales, test- taking strategies, content area, and CJ cognitive skill(s) for each practice question throughout the book are presented at the end of the book. In addition, the priority concept is identi- ed. e specic focus of each chapter is summarized below. Organization of the Book n Chapter 1, Introduction to the Cognitive Skills of Clinical Judgment , describes how clinical judgment builds on the nursing process and introduces you to the six essen- tial cognitive skills of the NCSBN Clinical Judgment Measurement Model (NCJMM). These cognitive skills are the basis for the new NGN test item types. n Chapter 2, Introduction to the NGN and the New NGN Item Types , explains the purpose and design of the NGN and presents the new test item types. An example of each item type is presented, and the correct responses are provided with brief rationales. n Chapter 3, Strategies for Answering NGN Questions: Recognize Cues , describes the CJ cognitive skill, Recognize Cues , which requires you to identify relevant clinical find- ings and decide which findings are of immediate con- cern and most important based on the clinical scenario. This chapter also identifies test items and enhanced test- taking strategies that you can use when answering items that measure this skill. Examples of these test items allow you the opportunity to practice applying these strategies within the chapter and in the practice test at the end of the chapter. a Please note: The NGN content provided in this book and on the Evolve site reects the information available at the time of production of this resource. The NCSBN research about NGN is ongoing, and changes in the items to measure each cognitive skill may be forthcoming. The NCSBN website at www.ncsbn.org provides you with the latest updates. n Chapter 4, Strategies for Answering NGN Questions: Analyze Cues , describes the CJ cognitive skill, Analyze Cues , which requires you to connect or link relevant cues to the clinical scenario, interpret these cues, and establish their significance. This chapter also identifies test items and enhanced test-taking strategies that you can use when answering items that measure this skill. Examples of these test items allow you the opportunity to practice applying these strategies within the chapter and in the practice test at the end of the chapter. n Chapter 5, Strategies for Answering NGN Questions: Prioritize Hypotheses , describes the CJ cognitive skill, Prioritize Hypotheses , which requires you to establish and rank client needs or hypotheses in order of priority. This chapter also identifies test items and enhanced test- taking strategies that you can use when answering items that measure this skill. Examples of these test items allow you the opportunity to practice applying these strategies within the chapter and in the practice test at the end of the chapter. n Chapter 6, Strategies for Answering NGN Questions: Generate Solutions , describes the CJ cognitive skill, Generate Solutions , which requires you to use knowledge of evidence-based solutions about treatments and inter- ventions that would address identified client needs and modify them to meet priorities of care. This chapter also identifies test items and enhanced test-taking strategies that you can use when answering items that measure this skill. Examples of these test items allow you the opportu- nity to practice applying these strategies within the chapter and in the practice test at the end of the chapter. n Chapter 7, Strategies for Answering NGN Questions: Take Action , describes the CJ cognitive skill, Take Action , which requires that you perform appropriate and necessary inter- ventions based on the client’s situation and generated solu- tions. This chapter also identifies test items and enhanced test-taking strategies that you can use when answering items that measure this skill. Examples of these test items allow you the opportunity to practice applying these strat- egies within the chapter and in the practice test at the end of the chapter. n Chapter 8, Strategies for Answering NGN Questions: Evaluate Outcomes , describes the CJ cognitive skill, Evaluate Outcomes , which requires that you examine out- comes and measure client progress towards meeting those outcomes in the plan of care. This chapter also identifies test items and enhanced test-taking strategies that you can use when answering items that measure this skill. Examples of these test items allow you the opportunity to practice applying these strategies within the chapter and in the practice test at the end of the chapter. Preface
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Preface ix n Chapter 9, Strategies for Answering NGN Stand-alone Items and Unfolding Case Studies , describes the differences between Stand-alone items and Unfolding Case Studies. Samples of Stand-alone items (including the bow-tie and trend) are illustrated, as well as Unfolding Case Studies. This chapter also identifies test items and enhanced test- taking strategies that you can use when answering ques- tions accompanying each type of case study. Examples of these test items allow you the opportunity to practice applying these strategies within the chapter. This chapter also points out external factors to consider in NGN cases, such as the environmental and individual factors. n Chapter , NGN Practice Test: Putting It All Together , pro- vides you with the opportunity to practice all of the new types of test items expected on the NGN, starting with Unfolding Cases Studies and ending with Stand-alone Bow-tie and Trend items. Special Features of the Book n NGN tips within each chapter. These unique tips provide the student with key points to remember, such as the NGN item type or cognitive skill (CS) features. n In-chapter sample questions are presented within Chapters 3 through 9 to provide examples of the new NGN test item types that best measure the clinical judgment cogni- tive skill presented in the chapter. Each question within the chapter specifies the priority concept and content area being tested. The answer, rationale, enhanced test-taking strategy, and references are also presented to help students learn the thinking process needed to select the correct test item response. n End-of-chapter practice questions are presented at the end of Chapters 3 through 8 to provide the opportunity for stu- dents to apply what they learned in each chapter and expe- rience answering selected test items that measure each of the NCSBN’s clinical judgment cognitive skills. Chapter 9 presents Stand-alone items, both Bow-tie and Trend items, and Unfolding Case Studies. n A comprehensive practice test is presented in Chapter 10 to allow students to apply what they learned in Chapters 1 through 9. Students have the opportunity to answer mul- tiple Unfolding Case Studies and Stand-alone items rep- resenting all clinical specialty areas. The priority concept, content area, answer, rationale, enhanced test-taking strat- egy, and reference for each test item are provided at the end of the book. n Enhanced test-taking strategies for the NGN. This unique feature walks students through the thinking process needed to navigate complex NGN cases. Each strategy explains how to apply the cognitive skill when considering the information presented in the clinical scenario. Each question is accompanied by test-taking strategies that are presented both narratively and in a table format to guide the student through a logical thinking process and to suit multiple learning styles. This thinking process with test- taking strategies will also help on current NCLEX-style (Stand-alone) items and nursing course exams. n Thinking Space. The Thinking Spaces located in the margins of the book is a place for personal note-taking. The student can use these spaces to write down new and important information they want to remember. To become most famil- iar with the cognitive skills and to build clinical judgment skills, using the Thinking Space to make important linkages between clinical scenario information and the cognitive skill will reinforce the aspects of the NCJMM model as the stu- dent is studying and preparing for the NGN. Special Features Found on Evolve e Evolve site accompanying this resource provides the stu- dent with all of the case studies and practice test questions in the book plus an additional 30 unfolding case studies, each with 6 NGN items. e book includes 60 single cases (each with 1 NGN item), 10 Stand-alone items (5 Bow-tie and 5 Trend), and 5 Unfolding Case Studies (items with 6 NGN items). is equals a total of 100 NGN items. en there are an additional 30 unfolding cases, each with 6 NGN items, and 4 additional Stand-alone items (2 Bow-tie and 2 Trend) total- ing 184 NGN items. Altogether, there are a total of 284 NGN items on Evolve. e Evolve site lists various category selections. You can select by type of question—either single case, Stand-alone items (either bow-tie or trend), or Unfolding Case Study. You can also select by the specic cognitive skill, content area, or priority concept. e table below illustrates the various cat- egories for selection. Type Cognitive Skill Content Area Priority Concept Single Stand- alone Unfolding Recognize Cues Analyze Cues Prioritize Hypotheses Generate Solutions Take Action Evaluate Outcomes Foundations of Nursing Maternal- Newborn Nursing Medical- Surgical Nursing Mental Health Nursing Pediatric Nursing Pharmacology Clotting Cognition Elimination Fluid and Electrolyte Balance Gas Exchange Glucose Regulation Immunity Mobility Mood and Aect Perfusion Stress and Coping Tissue Integrity How to Use This Book For Students As implied in the title, this book was written to help you be successful when taking the new test item types that will be
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Preface x part of the Next Generation NCLEX® (NGN). e rst two book chapters present a review of clinical judgment and the NGN item types. All new item types are based on the six cog- nitive (thinking) skills needed for safe, appropriate clinical judgment. Be sure that you are very familiar with this infor- mation before beginning to practice answering the test ques- tions later in the book. Chapters 3 through 8 describe each clinical judgment cog- nitive skill and provide general NGN Tips on how to answer test items that measure each skill. Sample NGN test items are then presented with the Rationale and Test-Taking Strategy for the correct and incorrect responses, followed by six end- of-chapter practice questions for you to answer. e practice questions in each chapter represent all content specialties. e rationale and test-taking strategy that you can use for each question to determine the correct answers are described in detail, with tables to help organize the information in each question. In addition, each test item is labeled by priority nursing concept and content specialty. References are also provided to help you review the content associated with each test item if needed. When working through Chapters 3 through 8, start with Chapters 3 and 4 early in your program so that you can learn how to determine the most important client ndings in a clinical scenario and what they mean (Recognize Cues and Analyze Cues). When you feel you have mastered these cogni- tive skills, work through Chapter 5, which will help you learn to prioritize client needs and the care required to meet them. Chapters 6 and 7 are focused on helping you learn to plan and implement nursing actions to meet the client’s needs. Finally, Chapter 8 will assist you in determining whether the client’s condition has improved aer care has been implemented. Aer working through Chapters 3 through 8 and when you feel ready to put all the cognitive skills together, Chapter 9 pro- vides examples for NGN Unfolding Case Studies and Stand- alone items. Chapter 10 presents a comprehensive practice test that simulates what you can expect on the NGN. e rationale and test-taking strategy for each practice test item in these chapters are described in detail. Many additional practice NGN test items are available on the Evolve site with rationale, test- taking strategy, content specialty, priority nursing concept, and reference for each Unfolding Case Study or Stand-alone item. For Faculty is book is designed for you to use as it is organized, begin- ning with helping students learn what CJ is and gain an understanding of each of the essential CJ cognitive skills as described in Chapter 1. Students in their rst nursing course should learn how to use these skills to make safe, appropri- ate clinical judgments to ensure client safety. If students are already making clinical judgments using these skills, Chap- ter 1 could be used for review. en students should become familiar with the NGN test design and new item types as pre- sented in Chapter 2. Finally, by the end of the rst semester (or other term), students should learn how to Recognize Cues and Analyze Cues (Chapters 3 and 4). ese cognitive skills focus on assessing the client, discerning how to determine which client ndings are the most important, and deciding what those ndings mean. End-of-chapter practice ques- tions can be used during class, online, simulation pre- or post-brieng, or clinical post-conference. e test items can be assigned to students as individuals or in groups to answer. Regardless of where or how practice test items are used, such as in the classroom, online, lab sessions, or clinical setting, be sure to review the answers, rationales, and strategies for arriving at the correct response(s) to identify and improve students’ thinking process as needed. As students progress to the next course, they should begin to learn how to prioritize care to determine what nursing actions they would plan and implement. Part of this thinking process includes an assessment to decide if the actions were eective and the client’s condition has improved. erefore students in this semester would focus on Chapters 5 through 8. Again, you can assign the practice items to students as indi- viduals or in groups and review the items to help students improve their thinking as needed. Chapters 9 and puts together all the cognitive skill steps and new NGN test item types—both Stand-alone items and Unfolding Case Studies. ese chapters can be used when- ever students are applying the individual CJ cognitive skills to successfully answer the new test items in preparation for the NGN. Assign these practice Unfolding Case Studies and Stand-alone items as individual student practice to determine any skill areas where improvement is needed. Students need- ing improvement can then review any of the six earlier chap- ters (Chapters 3 through 8) to hone their thinking skills. Faculty Tool Kit e Faculty Tool Kit was created to guide faculty in using this book with their students at any stage in the program to pre- pare them for the NGN. e Tool Kit: ■ Furnishes a guide for how to use this book, Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items, to prepare students for the NGN ■ Provides chapter-to-chapter strategic points to empha- size to students and ways to prepare students for an- swering NGN items ■ Provides suggestions for using the Evolve site accompa- nying this book ■ Presents step-by-step guides for writing Stand-alone items and Unfolding Case Studies ■ Presents step-by-step guides for writing NGN items ■ Species NCSBN resources that focus on NGN for stu- dents and faculty ■ Provides Elsevier resources and references for prepar- ing students for the NGN Additional Resources for Students n Ignatavicius, D.D. (2021). Developing Clinical Judgment for Professional Nursing and the Next-Generation NCLEX-RN® Examination. St. Louis: Elsevier.
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Preface xi is workbook helps students preparing to become RNs learn how to develop NCSBN’s six clinical judg- ment cognitive skills through practice in answering new NGN test item types embedded in unfolding and single-episode cases throughout the entire curriculum. Clinical scenarios are presented from more basic care to complex, multisystem care of clients in multiple spe- cialty areas. n Ignatavicius, D.D. (2022). Developing Clinical Judgment for Practical-Vocational Nursing and the Next-Generation NCLEX-PN® Examination. St. Louis: Elsevier. is workbook helps students preparing to become LPNs or LVNs learn how to develop NCSBN’s six clinical judg- ment cognitive skills through practice in answering new NGN test item types embedded in unfolding and single- episode cases. Clinical scenarios in multiple specialty areas are included, with a primary emphasis on the care of older adults in a variety of health care settings, and can be used throughout the entire curriculum. n Silvestri, L., & Silvestri, A. (2023). Saunders Comprehensive Review for the NCLEX-RN® Examination (9th ed.). St. Louis: Elsevier. is is an excellent resource to use both while you are in nursing school and in preparation for the NCLEX® examination. is book contains 20 units with 70 chap- ters, and each chapter is designed to identify specic components of nursing content. e book and accom- panying soware contain more than 5200 practice ques- tions and include alternate item format questions. e soware also contains a 75-question preassessment test that generates an individualized study calendar. A pos- tassessment test is included, as well as case studies and accompanying NGN item type practice questions. n Silvestri, L., & Silvestri, A. (2021). Saunders Q&A Review for the NCLEX-RN® Examination (8th ed.). St. Louis: Elsevier. is book and accompanying Evolve site provide you with more than 6000 practice questions based on the NCLEX-RN® test plan. Each practice question includes a priority nursing tip that provides you with a piece of important information to remember that will help you answer questions on nursing exams and on the NCLEX® examination. e chapters in this book are uniquely designed and are based on the NCLEX-RN® examina- tion test plan framework, including Client Needs and Integrated Processes. Alternate item format questions and accompanying NGN item type practice questions are included. With practice questions focused on the Client Needs, Integrated Processes, and Clinical Judg- ment/Cognitive Skills, you can assess your level of competence. n Silvestri, L., & Silvestri, A. (2020). HESI/Saunders Online Review Course for the NCLEX-RN® Examination. (3rd ed.) St. Louis: Elsevier. e online NCLEX-RN® review course provides a sys- tematic and individualized approach and addresses all areas of the test plan identied by the National Council of State Boards of Nursing, Inc. is self-paced online review contains 10 interactive, multimedia-rich mod- ules featuring animations and videos, practice ques- tions, end-of-lesson case studies, and much more! A diagnostic pretest generates a study calendar to guide your review. NCLEX®-style questions—including every type of alternate item format question—are provided, concluding with a comprehensive examination that will sharpen your test-taking skills. In addition, case studies and accompanying NGN practice questions are included. Unique videos that simulate a live review course focus on dicult subjects such as dysrhythmias and make them easier to understand. n Silvestri, L., & Silvestri, A. (2021). Saunders 2022-2023 Clinical Judgment and Test-Taking Strategies (7th ed.) St. Louis: Elsevier. is book is designed for both RN and PN nursing stu- dents and provides a foundation for understanding and unpacking the complexities of NCLEX® exam ques- tions, including alternate item formats. Saunders 2022- 2023 Clinical Judgment and Test-Taking Strategies 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® examination. Special nursing content tips are integrated along with other tips, such as clinical preparation tips and life-planning tips. ere are 1200 practice questions included so you can apply the testing strategies. NGN items and practice test ques- tions are also included on the Evolve site accompanying this resource. n Silvestri, L., & Silvestri, A. (2022). Saunders Comprehensive Review for the NCLEX-PN® Examination (8th ed.). St. Louis: Elsevier. is is an excellent resource to use both while you are in nursing school and in preparation for the NCLEX® exam- ination. is book contains 19 units and 65 chapters, and each chapter is designed to identify specic components of nursing content. e book and accompanying Evolve site contain more than 4500 practice questions and include alternate item format questions. e soware also contains a 75-question preassessment test that generates an individualized study calendar. A post-assessment test is also included, as well as case studies and accompanying NGN item type practice questions. n Silvestri, L., & Silvestri, A. (2020). Saunders Q&A Review for the NCLEX-PN® Examination (6th ed.). St. Louis: Elsevier. is book and accompanying Evolve site provide you with more than 5900 practice questions based on the NCLEX-PN test plan. Each practice question includes a priority nursing tip that provides you with a piece of important information to remember that will help you answer questions on nursing exams and on the NCLEX® examination. e chapters in this book are uniquely designed and are based on the NCLEX-PN® examina- tion test plan framework, including Client Needs and Integrated Processes. Alternate item format questions
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Preface xii and accompanying NGN item type practice questions are included. With practice questions focused on the Client Needs, Integrated Processes, and Clinical Judg- ment/Cognitive Skills, you can assess your level of competence. n Silvestri, L., & Silvestri, A. (2020). HESI/Saunders Online Review Course for the NCLEX-PN® Examination. (3rd ed.) St. Louis: Elsevier. is online NCLEX-PN® review course provides a sys- tematic and individualized approach and addresses all areas of the test plan identied by the National Council of State Boards of Nursing, Inc. is self-paced online review contains 10 interactive, multimedia-rich mod- ules featuring animations and videos, practice ques- tions, end-of-lesson case studies, and much more! A diagnostic pretest generates a study calendar to guide your review. NCLEX®-style questions—including every type of alternate item format question—are provided, concluding with a comprehensive examination that will sharpen your test-taking skills. In addition, case studies and accompanying NGN practice questions are included. Unique videos that simulate a live review course focus on dicult subjects such as dysrhythmias and make them easier to understand.
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xiii CHAPTER 1 Introduction to the Cognitive Skills of Clinical Judgment, 1 What Are the Purpose and Design of the Current NCLEX ® ?, 1 Why Is There a Need for NCLEX ® Change?, 2 What Is the NCSBN’S Denition and Model of Clinical Judgment?, 3 What Are the Six NCSBN Clinical Judgment Measurement Model Cognitive Skills?, 3 How Will the Six Clinical Judgment Skills Be Measured on the NGN?, 8 How Can You Prepare for the NGN?, 8 CHAPTER 2 Introduction to the NGN and the New NGN Item Types, Test Item Types Used for Unfolding Case Studies, 10 Test Item Types Used for Stand-alone Items, 20 CHAPTER 3 Strategies for Answering NGN Questions: Recognize Cues, 23 What Are Cues?, 23 How Are Client Findings (Cues) Presented in an NGN Clinical Scenario?, 23 Which Client Findings Are Relevant?, 24 Which Relevant Client Findings Are of Immediate Concern to the Nurse?, 25 What Types of Clinical Scenarios May Be Included on the NGN?, 25 What NGN Item Types Optimally Measure Recognize Cues?, 25 Practice Questions, 32 CHAPTER 4 Strategies for Answering NGN Questions: Analyze Cues, 36 How Do You Analyze Cues?, 36 How Does Analyzing Cues Help You Guide Client Care?, 36 How Do You Analyze Cues in an NGN Clinical Situation?, 37 What Will You Think About to Analyze Cues in This Clinical Scenario?, 38 Which Client Findings Are Most Important When Analyzing Cues?, 39 When Might You Need to Analyze Cues in a Clinical Situation?, 39 What NGN Item Types Optimally Measure Analyze Cues?, 39 Practice Questions, 48 CHAPTER 5 Strategies for Answering NGN Questions: Prioritize Hypotheses, 53 What Do Hypotheses Mean?, 53 What Does Prioritizing Mean?, 53 What to Consider When Prioritizing Hypotheses, 53 External Factors and Prioritizing Hypotheses, 54 How Do You Know That You Need to Prioritize?, 56 What Three Strategies Can You Use to Prioritize Hypotheses?, 57 How Do You Prioritize Hypotheses in an NGN Clinical Situation?, 58 What Will You Think About to Prioritize Hypotheses in This Clinical Scenario?, 59 What NGN Item Types Optimally Measure Prioritize Hypotheses?, 59 Practice Questions, CHAPTER 6 Strategies for Answering NGN Questions: Generate Solutions, 73 What to Consider When Generating Solutions, 73 The Plan of Care and Generating Solutions, 73 How Do You Know That You Need to Generate Solutions?, 73 How Do You Generate Solutions in an NGN Clinical Situation?, 74 What Will You Think About to Generate Solutions in This Clinical Scenario?, 75 What NGN Item Types Optimally Measure Generate Solutions?, 75 Practice Questions, 82 CHAPTER 7 Strategies for Answering NGN Questions: Take Action, 85 How Do You Know What Actions to Take?, 85 How Will Nursing Actions Be Tested?, 85 What NGN Item Types Optimally Measure Take Action?, Practice Questions, 92 CHAPTER 8 Strategies for Answering NGN Questions: Evaluate Outcomes, 96 How Do You Evaluate Outcomes?, 96 How Will Evaluate Outcomes Be Tested?, 97 NGN Question Stems Addressing Evaluate Outcomes, 97 What NGN Item Types Optimally Measure Evaluate Outcomes?, 98 Practice Questions, 105 Contents
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Contents xiv CHAPTER 9 Strategies for Answering NGN Stand-alone Items and Unfolding Case Studies, 111 What Are Stand-alone Items?, 111 What Are Unfolding Case Studies?, 125 How Are Stand-alone Items and Unfolding Case Studies Dierent?, 125 CHAPTER 10 NGN Practice Test: Putting It All Together, 134 Unfolding Case Studies, 134 Stand-alone Items, 157 Answers to Practice Questions, 163 References and Bibliography, 289
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1 is chapter will help yu understand the need fr change in the NCLEX® and the six clinical judgment cgnitive (thinking) skills that serve as the basis fr new test item types n the NGN. Aer a brief review f the current NCLEX® design, thinking skills needed t make safe, evidence-based clinical judgment are intrduced. General NGN Tips are prvided t help yu relate each thinking skill with the new exam. e new NGN item types will be included n the NCLEX® n sner than 2023 and are described in Chapter 2 f this bk. Specic Test-Taking Strategies that will help yu crrectly answer these new items are prvided thrughut ther chapters f this bk and accmpany all practice questins in the bk and n the Evlve site. Be sure t review this chapter before reading the rest f this bk r practicing NGN questins! What Are the Purpose and Design of the Current NCLEX ® ? As yu knw, prelicensure nursing educatin prgrams like the ne yu’re currently in prepare students fr eligibility t take either the NCLEX-RN® r the NCLEX-PN® aer graduatin. ese natinal licensure examinatins are develped and updated under the directin f the NCSBN. is rganizatin als versees the administratin f the NCLEX® in the United States, Canada, and a number f ther cuntries. e primary purpse f the NCSBN is t protect the public by prviding cmpe- tency assessments, such as the NCLEX®, that are sund and secure. e NCLEX® is cm- prehensive and reects current nursing practice. T ensure examinatin currency, the NCSBN cllects and analyzes nursing practice data every 3 years frm thusands f graduates t determine what knwledge and activities are required in their jbs as new nurses. is infrmatin is used t develp the cntent f the NCLEX® and is rganized in a new licensure test plan every 3 years (https://www.ncsbn.rg/testplans.htm). e test plan is rganized by fur majr Client Needs Categries, sme f which have sub- categries. In additin, ve Integrated Prcesses are dened and included thrughut the NCLEX® Test Plan as shwn in Bx 1.1 e NCLEX® currently measures the new graduate’s minimum cmpetence in safety t ensure public prtectin thrugh a variety f test items. Mst f the test items (abut 95%) are either Multiple Chice r Multiple Respnse, als knwn as Select All at Apply (SATA) questins. Fr each f these item types, client infrmatin is presented in a shrt clinical scenari fllwed by a questin abut the nurse’s rle in client care. Examples f these test item types are presented in Bx 1.2 As yu’ll ntice in the afrementined test items, each questin fcuses n what the nurse wuld d r say in respnse t specic client data. Only the client infrmatin that is the mst imprtant, relevant, r, in sme cases, f immediate cncern t the nurse is presented in the clinical situatin. e answer is then selected frm a list f chices prvided. e narrw fcus f these test items des nt represent the scpe f actual nursing practice and des nt allw measurement f clinical judgment. Rather, these types f items reect whether the candidate can distinguish between right and wrng. At this pint in yur educatin, yu likely are very familiar with these item types n yur curse exams. Introduction to the Cognitive Skills of Clinical Judgment C H A P T E R 1 THINKING SPACE
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Strategies for Student Success on the Next Generation NCLEX ® (NGN) Test Items 2 Why Is There a Need for NCLEX ® Change? Althugh natinal NCLEX® rst-time pass rates fr bth RN and PN graduates have been abve 80% fr many years, health care emplyers cntinue t reprt increasing errrs in client care and lack f apprpriate clinical judgment skills amng new nursing graduates. A recent literature review cnducted by the NCSBN fund that 50% f all nurses have been invlved in at least ne client errr. Sixty percent f thse errrs were the result f pr clinical judgment. Over 80% f nursing emplyers are not satised with the ability f new nursing graduates t make accurate r apprpriate clinical deci- sins regarding client care. In respnse t these data, the NCSBN began t questin if the NCLEX® was measuring “the best thing” t prtect the public. e 2013–2014 Strategic Practice Analysis f activities perfrmed by practicing RNs and RN rle experts cnrmed the imprtance f sund clinical judgment skills fr Integrated Processes Client Needs Categories/Subcategories Nursing Process a Teaching and Learning Communication and Documentation Caring Culture and Spirituality Safe and Eective Care Environment Management of Care b Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity Basic Care and Comfort Pharmacological and Parenteral Therapies c Reduction of Risk Potential Physiological Adaptation BOX 1.1 NCLEX-RN ® Test Plan Organizing Concepts a This Integrated Process on the NCLEX-PN ® Test Plan is the Problem-Solving Process. b This Client Needs subcategory on the NCLEX-PN ® Test Plan is Coordinated Care. c This Client Needs subcategory on the NCLEX-PN ® Test Plan is Pharmacological Therapies. Example : Multiple Choice Single Response The nurse is planning care for a client admitted to the hospital with a diagnosis of acute pancreatitis and controlled hypertension. What is the nurse’s priority for the client’s care at this time? ☐ Administer an antiemetic medication. ☐ Manage the client’s acute pain. ☐ Monitor the client’s blood pressure. ☐ Administer supplemental oxygen. Example : Multiple Response (Select All That Apply) The nurse is assessing an adolescent who was taken to the ED for threatening to commit suicide. What is (are) the most appropriate question(s) for the nurse to ask the client at this time? Select all that apply. ☐ “What made you want to kill yourself?” ☐ “Do you have a plan for killing yourself?” ☐ “Do you plan to kill yourself with anyone else?” ☐ “Is this the ųrst time you’ve threatened to kill yourself?” ☐ “Did you write a suicide note to explain why you are doing this?” BOX 1.2 Examples of Current Multiple Choice and Multiple Response NCLEX ® Test Items Note: Indicates correct response(s). THINKING SPACE
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CHAPTER 1 Introduction to the Cognitive Skills of Clinical Judgment 3 many tasks and activities perfrmed by entry-level nurses. is analysis als highlighted that nurses tday make mre cmplex decisins t prvide safe care fr clients with higher acuity and advanced age. e NCSBN literature review als fund that the nurse’s primary practice activity is the ability t prblem slve and critically think—thinking prcesses needed fr mak- ing apprpriate clinical judgments. Problem solving is the prcess f develping and evaluating nursing slutins r appraches t client prblems. Critical thinking can be described as a prcess requiring the use f lgic and clinical reasning t identify the strengths and weaknesses f nursing slutins r appraches t client prblems. e NCBSN built n these prcess descriptins t create a denitin and mdel f clinical judgment t be used as a basis fr develping new NCLEX® test item types. What Is the NCSBN’S Definition and Model of Clinical Judgment? As a result f the literature review, Strategic Practice Analysis, and input frm a vari- ety f nurse clinicians and educatrs, the NCSBN develped this denitin f clinical judgment: Clinical judgment is dened as the observed outcome of critical thinking and decision making. It is an iterative process that uses nursing knowledge to observe and assess present- ing situations, identify a prioritized client concern, and generate the best possible evidence- based solutions in order to deliver safe client care. S, what des this denitin mean fr yu as a nursing student and future prfes- sinal nurse? ink abut each f these key pints in the clinical judgment denitin: ■ Recgnize that clinical judgment is the result r outcome of thinking t make deci- sins abut client care when ptential r actual health prblems ccur. The same prcess f thinking t make clinical decisins ccurs repeatedly as yu manage client prblems (iterative process). ■ Acquire and recall nursing knowledge t make apprpriate clinical judgments. (Hwever, having knwledge des nt guarantee that an accurate r apprpriate clinical judgment will be made.) ■ Learn hw t prioritize a client’s need fr care based n the data presented abut a clinical situatin. ■ Be familiar with the best current evidence regarding a presented client situatin s yu can cme up with pssible slutins r appraches fr care t keep the client safe. Yu will want t acquire these skills and a strng knwledge base during yur nurs- ing prgram t be ready fr a dynamic, cmplex health care system and the NGN. Aer the NCSBN develped its denitin f clinical judgment, the rganizatin cre- ated a mdel f clinical judgment, called the NCSBN Clinical Judgment Measurement Mdel (NCJMM). As the name implies, this mdel was created t measure the nursing graduate’s ability t make clinical judgments. Althugh it is nt imprtant fr yu t be familiar with the entire mdel, it is essential that yu master the thinking skills assci- ated with clinical judgment. e NCJMM identies six cgnitive (thinking) skills that are needed fr eective prfessinal nursing practice and serve as the basis fr the new NGN test item types. ese skills are smetimes referred t as Layer 3 f the NCJMM and are intrduced in the next sectin f this chapter. e NCJMM als identies factrs that inuence the ability f nurses t make appr- priate clinical judgments. Examples f these Envirnmental and Individual factrs, smetimes referred t as Layer 4 f the NCJMM, are listed in Table 1.1. Individual fac- trs are thse related t the nursing graduate candidate taking the NGN. What Are the Six NCSBN Clinical Judgment Measurement Model Cognitive Skills? e NGN includes new test item types that measure the six cgnitive skills f clinical judgment. Each f these thinking skills, smetimes referred t as cgnitive prcesses, THINKING SPACE
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Strategies for Student Success on the Next Generation NCLEX ® (NGN) Test Items 4 is intrduced in this chapter. Chapters 3 thrugh 8 in this bk describe these skills in mre detail and present examples f NGN test items that are designed t measure each skill. e six cgnitive skills essential fr clinical judgment are listed in Bx 1.3 with key questins that explain the fcus f each skill. Recognize Cues Fr clients in any health care setting, the nurse cllects client data frm a number f surces. Cues are client ndings r assessment data that prvide infrmatin fr nurses as a basis fr decisin making t make apprpriate clinical judgments and can be divided int fur majr types as listed belw. Chapter 3 describes these surces f cues in mre detail. ■ Envirnmental cues; e.g., presence f family member ■ Client bservatin cues; e.g., signs and symptms ■ Medical recrd cues; e.g., lab values r vital signs ■ Time pressure cues; e.g., rapid clinical decline In actual clinical practice, the nurse reviews all client ndings t determine which data are mst imprtant, relevant, and, in sme cases, f immediate cncern. T help yu Recognize Cues, ask yurself which client data are mst imprtant in the presented clinical scenari. Carefully review the client’s presenting data, such as vital signs and medical diagnsis, t determine their relevance. Fr example, a heart rate f 140 bpm wuld be f immediate cncern fr a middle-aged adult, but is within the typical range fr a newbrn. In sme clinical scenaris the client has a histry f ne r mre acute and/r chrnic health prblems. Fr example, an lder adult with a lng histry f COPD may have a Pao 2 f 65 mm Hg. is arterial xygen level is abnrmal because it is belw the usual range f 80 t 100 mm Hg. Hwever, fr this client, the lw arterial xygen level is likely nt imprtant r f immediate cncern because it is expected. Many clients with advanced COPD have chrnically lw arterial xygen, but they cmpensate by using breathing techniques cmbined with lw-w supplemental xygen. Analyze Cues Aer relevant cues have been identied in a clinical scenari, the nurse rganizes and links them t the client’s presenting clinical situatin. Ask yurself: “What d the rel- evant client data mean r indicate at this time?” Fr example, cnsider a middle-aged Recognize Cues: What matters most? Analyze Cues: What could it mean? Prioritize Hypotheses: Where do I start? Generate Solutions: What can I do? Take Action: What will I do? Evaluate Outcomes: Did it help? BOX 1.3 Clinical Judgment Cognitive Skills With Key Questions Remember: To Recognize Cues, carefully review the client’s as- sessment data like developmental age and history to help determine if ndings are relevant or of im- mediate concern to the nurse. NGN TIP TABLE 1.1 Example of Environmental and Individual Factors That Inuence Clinical Judgment Examples of Environmental Factors Examples of Individual Factors Environment Medical records Time pressure Task complexity Resources Cultural considerations Client observation Consequences and risks Knowledge Skills Specialty Prior experience Level of experience Candidate characteristics
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CHAPTER 1 Introduction to the Cognitive Skills of Clinical Judgment 5 client wh had a small bwel resectin 2 days ag and begins having increasing abdm- inal pain, distentin, vmiting, and absent bwel sunds. ese data, when gruped tgether, are cnsistent with a pstperative paralytic ileus. T link these assessment ndings with an ileus, yu need knwledge f pathphysilgy, especially signs and symptms. In sme clinical scenaris, the client may have multiple relevant cues that are assci- ated with several dierent client cnditins. e example in Bx 1.4 illustrates this type f scenari fr an lder adult hspitalized fr a urinary tract infectin and sepsis. In this inking Activity, yu wuld need t review each client nding t determine if it is cnsistent with ne r mre f the specied client cnditins. In this example, ne nding may be linked with tw r three client cnditins, such as generalized weakness and acute cnfusin. Hwever, dyspnea n exertin is assci- ated with nly ne f the listed prblems—anemia. e crrect respnses t the ink- ing Activity are fund in Bx 1.5 In ther clinical scenaris, the client may nt be experiencing an actual health prb- lem, but is at risk fr ne r mre ptential cmplicatins. Fr example, the wman wh recently had a spntaneus vaginal delivery is at risk fr pstpartum hemrrhage within the rst 24 hurs, particularly if the uterus becmes bggy (a client bservatin cue). In sme clinical situatins then, part f the thinking prcess t Analyze Cues is t identify if cues are linked t r assciated with ptential cmplicatins. Prioritize Hypotheses Aer rganizing, gruping, and linking relevant client ndings with actual r ptential client cnditins, the next cgnitive skill requires yu t narrw dwn what the data mean and priritize the client’s prblems r needs. Althugh yu may have learned abut pririty decisin-making mdels such as the ABCs r Maslw’s Hierarchy f Needs, these mdels are en nt very useful in helping yu make clinical judgments in mre cmplex clinical situatins. T Prioritize Hypotheses, review and evaluate each f the client’s needs r health prb- lems in the clinical situatin. en rank them t decide what is most likely the pririty Client Finding Dehydration Hypernatremia Anemia Generalized weakness Acute confusion Dry mouth Increased heart rate Dyspnea on exertion BOX 1.4 Example of a Thinking Activity That Requires the Ability to Analyze Cues Remember: To Analyze Cues, you are not required to make a medi cal diagnosis but rather will be expected to connect or link client ndings with selected client con- ditions or health problems, either actual or potential. NGN TIP Client Assessment Finding Dehydration Hypernatremia Anemia Generalized weakness X X X Acute confusion X X X Dry mouth X X Increased heart rate X X X Dyspnea on exertion X BOX 1.5 Example of a Thinking Activity That Requires the Ability to Analyze Cues
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Strategies for Student Success on the Next Generation NCLEX ® (NGN) Test Items 6 health prblem. Evaluate factrs in the clinical situatin such as urgency, risk, diculty, and time sensitivity fr the client. Fr example, cnsider this clinical situatin: A 42-year-old postpartum client who just gave birth to a third child in 4 years reports severe “aerbirth pains” of 9/10 on a 0 to 10 pain intensity scale. e client also reports having problems with getting the baby to latch for breast-feeding/chest-feeding. e nurse assesses that the client has a boggy uterus and is saturating a peri-pad every 20 to 30 minutes. In this example, the client has three prblems that yu wuld evaluate and rank in this rder: 1. Excessive pstpartum bleeding due t bggy uterus 2. Severe abdminal pain due t uterine cntractins 3. Diculty with breast-feeding/chest-feeding due t inability f baby t latch e pririty fr this client at this time is t manage excessive pstpartum bleeding because the client culd becme hypvlemic and develp shck. In this situatin, man- aging the client’s bleeding is mre urgent than managing severe pain r breast-feeding/ chest-feeding diculty t prevent the risk f a life-threatening cmplicatin. Generate Solutions Aer identifying the client’s pririty prblem in a given clinical scenari, yu want t think abut all the pssible actins that can be used t reslve r manage the prblem. T assist in selecting the pssible actins r apprach t care yu might include, rst determine what utcmes are desired r expected fr the client. Fr example, cnsider this scenari: e birth parent of an 11-year-old brings the child to the ED for a right forearm injury experienced as a result of a scooter accident. e nurse observes that the child is crying and guarding the right arm, which is swollen, deformed, and bruised. e child is le-handed. During the head-to-toe assessment, the nurse notes old bruising on the le side of the child’s chest and scarring on both upper thighs. Both knees have large abrasions with small stones and dirt embedded in them. e child denies having had any previous accidents or injuries. An x-ray conrms a right nondisplaced metaphyseal ulnar fracture. In this example, the client has an acute injury and signs f previus injuries, pssibly frm abuse. e desired utcmes wuld include that the client: ■ States that pain is n mre than a 2–3/10 n a 0 t 10 pain intensity scale ■ Des nt experience cmprmised neurvascular cmprmise in the right arm ■ Has decreased swelling f the right arm ■ Will experience healing f bilateral knee abrasins withut infectin ■ Is safe at hme (n neglect r abuse) with the birth parent r ther family/significant ther e next step in this thinking prcess is t identify multiple ptential actins r nurs- ing interventins that culd achieve the desired utcmes. Als identify which actins wuld be avided r are cntraindicated. T develp a list f actins r interventins fr this pediatric client, yu need knwledge f child develpment, fracture treatment, child abuse, and pain management. Sme nursing actins may fcus n cllecting additinal infrmatin abut the cli- ent. Fr instance, the nurse wuld likely want t interview the birth parent t btain infrmatin abut the ld bruising and scarring bserved n the child’s chest and thighs. Other ptential actins that culd help achieve the desired utcmes in this clinical situatin include: ■ States that pain is n mre than a 2–3/10 n a 0 t 10 pain intensity scale ■ Administer nnpiid pain medicatin; avid piids if pssible. ■ Prvide distractin fr the child, such as an iPad r gaming device. ■ Reassure the child that analgesics will be available as needed aer discharge. Remember: The urgency of a clini- cal situation and risk to the client are important factors that will help you Prioritize Hypotheses. NGN TIP Remember: To Generate Solutions to meet a client’s priority needs, determine the client’s desired or expected outcomes rst. NGN TIP
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CHAPTER 1 Introduction to the Cognitive Skills of Clinical Judgment 7 ■ Des nt experience cmprmised neurvascular cmprmise in the right arm ■ Assist in applying a right synthetic frearm cast. ■ Mnitr the child’s right arm neurvascular status aer cast applicatin. ■ Has decreased swelling f the right arm ■ Apply ice pack t arm utside cast and teach child need t use ice fr the next 24 hurs. ■ Teach child t keep arm elevated as much as pssible. ■ Will experience healing f bilateral knee abrasins withut infectin ■ Clean bth knees t remve debris and dirt. ■ Apply triple antibitic cream n pen areas and cver with clean gauze. ■ Apply tpical lidcaine t knees t decrease pain. ■ Is safe at hme (n neglect r abuse) with the birth parent r ther family/significant ther ■ Cmmunicate cncern abut child’s safety t primary health care prvider. ■ Cnsult with the scial wrker abut the child’s ptential safety risk, family situa- tin, and pssible change in placement f the child. ■ Reprt ptential child abuse t Child Prtective Services (CPS). Aer the list f ptential actins has been identied fr each desired utcme, deter- mine which actins shuld be implemented t meet the pririty needs f the client in the Take Action prcess. Take Action Deciding which actin t implement is the fcus f this clinical judgment thinking skill. Aer generating a list f pssible interventins, determine the mst apprpriate interventin r cmbinatin f interventins that will reslve r manage the client’s pririty health prblems r cncerns. Als determine hw each interventin will be implemented. Examples f methds t accmplish r implement interventins include what t cmmunicate, dcument, perfrm, administer, teach, r request frm a primary health care prvider r ther member f the health care team. Fr example, in the pediatric clinical scenari described in the previus sectin n Generate Solutions, yu might request a cnsultatin with the scial wrker t interview the birth parent abut the child’s injuries and hme situatin. Scial wrkers are experts in interviewing and addressing family situatins, and can determine if the child’s inju- ries are ptentially cnsistent with abuse. When deciding n hw t implement interventins, avid memrized textbk meth- ds r prcedures. Instead cnsider the elements f the clinical situatin t determine which apprach t use. Fr example, teaching the birth parent abut the care f the child aer discharge wuld be apprpriate fr mst situatins. Hwever, in the pediatric clinical example, yu might not want t teach the birth parent abut hme care aer discharge frm the ED until it is determined whether the child will g hme with the birth parent. If abuse is suspected, the child wuld be remved frm the current family situatin. Evaluate Outcomes e last clinical judgment thinking skill is t determine if the interventins imple- mented fr the client reslved r eectively managed the health prblem(s). e best way t make that determinatin is t cmpare what the desired r expected utcmes are with current client ndings r bserved utcmes. Ask yurself, “Which assessment ndings/signs and symptms indicate that the client’s cnditin has imprved?” “Which ndings indicate that the client’s cnditin has declined?” Fr example, cnsider this clinical scenari: A 78-year-old client has been hospitalized for 6 days for exacerbation of chronic heart failure. On admission the client was placed on supplemental oxygen and IV furosemide for peripheral Remember: When deciding to Take Action, avoid memorized textbook methods and proce dures; instead, customize your action to meet the needs of the client in the clinical scenario. NGN TIP THINKING SPACE
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Strategies for Student Success on the Next Generation NCLEX ® (NGN) Test Items 8 edema and impending pulmonary edema. e primary health care provider adjusted the cli- ent’s cardiac medications and restricted salt intake (no added table salt). e nurse preparing for the client’s discharge performs a head-to-toe assessment to determine the eectiveness of heart failure management. e nurse documents the following client ndings: ■ Lungs clear with no adventitious breath sounds ■ No shortness of breath when walking short distances ■ Lost 5 lb (2.3 kg) during hospital stay ■ Bilateral ankle and foot edema decreased from 3+ to 1+ ■ States planning to continue using table salt at home In this example, all f the client assessment data at the time f discharge demnstrate that the interventins used t manage heart failure were eective because the client is imprving. Hwever, the client plans t cntinue using table salt at hme, which culd cntribute t anther exacerbatin f heart failure. e nurse may need t reinfrce teaching abut the relatinship f sdium t uid retentin r cnsult with the regis- tered dietitian nutritinist t prvide the teaching. How Will the Six Clinical Judgment Skills Be Measured on the NGN? e new NGN exam is cmpsed f current test item types and new test item types. e ttal number f test items shuld range between 85 and 150 ttal questins. e six NCJMM cgnitive skills intrduced in this chapter are measured n the NGN thrugh use f a variety f new test item types that are embedded int tw types f case studies—the Unflding Case Study and the Stand-alne item. Bth types f cases present a clinical scenari and include part f a medical recrd similar t the recrd shwn in the gure. Additinal medical recrd tabs may be included as the scenari requires. e Unfolding Case Study presents the client ver time thrugh several phases f care in the clinical scenari. It is en referred t as the NGN Case Study. e time between phases can be minutes, hurs, r even days. e client may initially be evaluated in an ED, acute care hspital, clinic, schl, r urgent care center. As the scenari changes, r “unflds,” new NGN test items require that the candidate use the infrmatin in the current phase f the client’s care t answer each questin. Nursing candidates can expect t have three NGN Case Studies with six questins each. Each f the six questins rep- resents ne f the clinical judgment cgnitive skills discussed earlier. e Stand-alone item smetimes referred t as the Stand-alne clinical judgment item, presents a client at ne pint in time and includes ne f the new NGN test item types. Each item measures ne r mre f the six clinical judgment cgnitive skills. Nursing candidates are expected t have varying numbers f Stand-alne items n the NGN, depending n the candidate’s ability in taking the exam. Hwever, it is expected that mst candidates will have abut seven Stand-alne items. How Can You Prepare for the NGN? In additin t using this bk, ther resurces such as the Developing Clinical Judgment wrkbks written by ne f this bk’s authrs (D.D.I.) prvide thinking exercises t Remember: To Evaluate Out- comes , compare desired or expected client outcomes with current observed outcomes. NGN TIP Health History Nurses’ Notes Vital Signs Laboratory Results
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CHAPTER 1 Introduction to the Cognitive Skills of Clinical Judgment 9 help yu master the six cgnitive skills t make apprpriate clinical judgments. If yu need help with basic NCLEX® test-taking strategies and want beginning practice with NGN test items, tw f this bk’s authrs (L.A.S. and A.E.S.) created a bk entitled Clinical Judgment and Test-Taking Strategies. All f these bks are included in the NGN Resurce list at the end f this bk. Anther way t prepare fr the NGN is t practice multiple test items in the Unfld- ing Case Study and Stand-alne item frmats. NGN practice questins are lcated at the end f Chapters 3 thrugh 8 f this bk. Chapter 9 illustrates Stand-alne and Unfld- ing Case Studies with apprpriate NGN test items. Chapter is a cmprehensive NGN Practice Test that includes questins in all specialty areas. Crrect answers, ratinales, test-taking strategies, specialty cntent area, selected cncepts, and references are avail- able fr all NGN practice questins in the bk. In additin t the questins in this bk, 50 Stand-alne items and Unflding Case Studies with accmpanying questins are available fr yur practice n the Elsevier Evlve site. Categries fr selectin f questins n Evlve include Cntent Area, Prir- ity Cncept, and Clinical Judgment Cgnitive Skill. Nw that yu have been intrduced t the six cgnitive skills needed t make appr- priate clinical judgment, yu are ready t learn abut the new NGN test item types. e next chapter describes and illustrates examples f the new NGN test item types. THINKING SPACE
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As described in Chapter 1, the NGN will be composed of current test item types and new test item types. e six NCJMM cognitive (thinking) skills introduced in Chapter 1 will be measured on the NGN through use of a variety of new test item types that are embedded into two types of cases—the Unfolding Case Study and the Stand-alone item. Both types of cases present a common, realistic clinical situation that new graduates will likely encounter. is chapter describes the 15 new item types that will likely be part of the NGN. An example of each item type is presented and the correct responses are provided with brief rationales. Multiple examples of all item types, each with detailed Rationales, Content Area, Priority Concept, Cognitive Skill, and References, are presented throughout this book. Unlike the current NCLEX® items, most new NGN items will be scored using partial credit rather than being completely correct or incorrect. is means that for most NGN items you will receive credit for any correct responses but will not receive credit for incorrect responses. Test Item Types Used for Unfolding Case Studies As described in Chapter 1, the Unfolding Case Study, also known as the NGN Case Study, presents a client and the initial data describing the clinical situation. ese data will typi- cally be part of a client medical record. e client either will be experiencing an urgent or emergent health problem or will be at risk for experiencing an urgent or emergent health problem. You’ll need the information in the initial clinical scenario to answer the rst NGN test item, which will measure the clinical judgment cognitive skill of Recognize Cues. e second NGN test item will likely measure your ability to Analyze Cues. As the clinical scenario continues, the client’s condition will change over time through several phases of care in the clinical scenario. Four additional NGN test items will measure the other clinical judgment cognitive skills based on what client data are provided. Twelve of the new item types on the NGN will be integrated into multiple unfolding case studies. e remaining two types will be used for the Stand-alone items discussed later in this chapter. Table 2.1 organizes these item types by major category and the cog- nitive skills that they best measure. Chapter 1 describes each of the six cognitive skills essential for making appropriate clinical judgment when caring for clients across the lifespan in a variety of health care settings. Chapter 9 provides examples of complete unfolding cases with six accompanying test items and examples of the two types of Stand-alone items. e new item types that will be used as part of unfolding cases are described in the following sections. Multiple Choice Test Items Multiple choice test items have been a large part of the NCLEX® for many years. ese items currently present a short clinical scenario and four choices with one correct response and three distractors (the wrong options) (see Box 1.2 in Chapter 1 for an example). For the NGN, there are two variations of the multiple choice item type: Mul- tiple Choice Single Response and Matrix Multiple Choice. Introduction to the NGN and the New NGN Item Types C H A P T E R 2 Remember: Data presented in the new NGN test item formats will usually be presented as part of a medical record as shown in the gure in Chapter 1. Many of the test items presented in this book are displayed in the medical record format. NGN TIP Remember: Expect each unfold- ing case on the NGN to present client data that change over time (minutes, hours, days) and six NGN test items, each measuring one of the six clinical judgment cognitive skills. NGN TIP
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C H A P T E R 2 Introduction to the NGN and the New NGN Item Types 11 Multiple Choice Single Response Item On the NGN, the format for the Multiple Choice Single Response test item will be similar to the current NCLEX® format. However, the clinical scenario will be longer with more infor- mation about the client situation, usually within a portion of the medical record. In addition, the number of responses will not be restricted to four options, and as many as 10 options may be included. Sample Question 2.1 shows an example of this type of item to measure the clinical judgment cognitive skill of Take Action for an adult client with a mental health issue. TABLE 2.1 NGN Item Types for Unfolding Case Studies NGN Item Types and Variations Cognitive Skills That Can Be Optimally Measured Multiple Choice Multiple Choice Single Response Matrix Multiple Choice Recognize Cues Analyze Cues Prioritize Hypotheses (except Matrix Multiple Choice) Generate Solutions Take Action Evaluate Outcomes Multiple Response Multiple Response Select All That Apply Multiple Response Select N Multiple Response Grouping Matrix Multiple Response Recognize Cues Analyze Cues Prioritize Hypotheses (except Matrix Multiple Choice) Generate Solutions Take Action Evaluate Outcomes Drop-Down Drop-Down Cloze Drop-Down Rationale Drop-Down in Table (may be replaced by a Drag-and-Drop in Table) Recognize Cues Analyze Cues Prioritize Hypotheses Generate Solutions Take Action Evaluate Outcomes Drag-and-Drop Drag-and-Drop Cloze Drag-and-Drop Rationale Recognize Cues Analyze Cues Prioritize Hypotheses Generate Solutions Take Action Evaluate Outcomes Highlight Highlight in Text Highlight in Table Recognize Cues Evaluate Outcomes Based on the client information provided, what is the nurse’s rst action? ☐ Ask the client’s friends to check the client for additional weapons. ☐ Reassure the client that the client is safe and secure in the ED. ☐ Call Security for assistance. Allow the client to vent own feelings. ☐ Administer an antianxiety medication. ☐ Distract the client and guide the client to practice coping skills. Multiple Choice Single Response Sample Question . Health History Nurses’ Notes Vital Signs Laboratory Results : A 28-year-old client is brought to the ED by friends, who state that the client became violent this evening in a local bar after a partner “break up.” The client accused the partner of “cheating” and pulled out a knife. The cli- ent’s friends were able to stop the client and take the knife before any harm occurred. They state that they have never seen the client act like this and are worried that something might be seriously wrong. Currently the client seems agi- tated and restless, and begins pacing in the ED demand- ing to “see my partner right now.”
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Strategies for Student Success on the Next Generation NCLEX ® (NGN) Test Items 12 Remember: As with any client who is upset, paranoid, angry, or potentially violent, you would rst allow the client to vent feel- ings, which may help diuse the situation. Allowing a client to vent and keeping the client and sta safe are the initial focus of nursing care when encounter- ing any client with an actual or potential mental health problem or crisis. NGN TIP The nurse provides health teaching for a 70-year-old client who had a TKA 3 days ago and is preparing to go home with a daughter. For each client statement, click or specify (with an X ) whether the statement indicates understanding or no understanding of the teaching provided. Client Statement Understanding No Understanding “I’ll call my surgeon if my incision gets red or has drainage.” ☐ “I can stop taking my blood thinner when I get home.” ☐ “I’ll have physical therapy for about a week.” ☐ “I’m allowed to bear weight on my right leg.” ☐ “I can probably drive in a few months.” ☐ Matrix Multiple Choice Sample Question . Rationale: e rst nursing action is to allow the client to vent feelings. is action may help to de-escalate and decrease the client’s agitation and restlessness. e nurse would not want to ask friends to check for weapons because they could possibly be harmed. Although calling Security may be needed later, the client may feel threatened by the pres- ence of that authority gure and become more agitated or violent at this time. Reassuring the client that the client is safe does not address the concern. Although the client is agi- tated, distraction and practicing coping skills may be a better option at a later time aer the current concern is addressed. Medication is usually the last resort unless needed to calm the client so that communication can occur. Although the client is restless and pacing in the ED, there is no evidence that the client would not vent feelings to the nurse. Matrix Multiple Choice Item e Matrix Multiple Choice test item is more complex than the Multiple Choice Single Response item. A Matrix Multiple Choice item provides a clinical scenario and selected data about the client. e test item is structured in a tabular format (matrix) with at least four rows and three columns. For this item, you would select only one response for each row. Sample Question 2.2 shows an example of this type of item to measure the clinical judgment cognitive skill of Evaluate Outcomes for an adult client who has had a surgical procedure. Rationale: As indicated in the test item, the client’s statements that are not correct and show that the client does not understand the health teaching include: “I can stop taking my blood thinner when I get home,” and “I’ll have physical therapy for about a week.” Clients who have total joint arthroplasty (especially knee and hip) are at a high risk for venous thromboem- bolism—DVT or PE. To help prevent these problems, the client is prescribed an oral antico- agulant, which is typically continued for 10 days to several weeks aer surgery and should be taken aer the client is home. e client would call the surgeon if the incision becomes red and/or has drainage because these symptoms indicate possible infection. Aer surgery, most clients have 3 to 6 weeks of physical therapy depending on the type of prothesis and the client’s overall health and tolerance. e surgical joint is oen sti, painful, and swollen, which limits the client’s range of motion; however, weight bearing to tolerance helps promote ambulation and increase muscle strength. Physi- cal therapy plus exercises that clients practice every day help to improve joint function and independence. e client will be allowed to drive when muscle strength and joint mobility improve. Driving is dicult until the surgical knee is able to ex more than 90 degrees. is goal may not be achieved for 6 to 8 weeks or more aer surgery.
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C H A P T E R 2 Introduction to the NGN and the New NGN Item Types 13 Multiple Response Test Items Multiple Response test items have been a large part of the NCLEX® for many years. ese items currently present a short clinical scenario with ve or six options. e cor- rect response(s) could be one, some, or all options (see Box 1.2 in Chapter 1 for an example). For the NGN, there are four variations of the Multiple Response test item: ■ Multiple Response Select All That Apply Item ■ Multiple Response Select N Item ■ Multiple Response Grouping Item ■ Matrix Multiple Response Item Multiple Response Select All That Apply Item On the NGN, the format for the Multiple Response Select All at Apply test item will be similar to the current NCLEX® format. However, the clinical scenario will be longer with more information about the client situation, usually within a portion of the medi- cal record. e item will have at least ve choices and no more than 10 choices. e cor- rect response could be one, some, or all options. Sample Question 2.3 shows an example of this type of item to measure the clinical judgment cognitive skill of Analyze Cues for an older client who is residing in an assisted-living facility and who experiences acute confusion. Rationale: e client’s assessment ndings indicate that the client likely has a UTI (as evi- denced by multiple bacteria in the urine). Fever, acute confusion, and a low BP suggest that the client is dehydrated and may have urosepsis. Acute confusion is also known as delirium, a common assessment nding in older clients who have a UTI. Because the client has type 2 diabetes, the client also is likely experiencing a diabetic complication called hyperglycemic hyperosmolar syndrome. e client’s elevated blood glucose and dehydration are consistent with a hyperosmolar state. A low blood pressure is also consistent with dehydration. Multiple Response Select N Item e Multiple Response Select N test item is similar to the Multiple Response Select All at Apply item except that the number of required correct responses is specied in the question. is item will also have at least ve options but no more than 10 options from which to choose. Sample Question 2.4 shows an example of this type of item to measure the clinical judgment cognitive skill of Recognize Cues for an adult client who has new onset of symptoms. An 81-year-old client was admitted to an acute care unit from an assisted-living facility with a low-grade fever and acute confusion. The client’s daughter tells the admitting nurse that the client’s mother had a stroke 2 years ago that resulted in left hemiparesis and urinary incontinence, and the client has been in the assisted- living facility for the past 5 months. The client has a long history of DM type 2, which has been well controlled. Until this morning, the client’s daughter had not been allowed to visit the facility due to the COVID-19 pandemic. During the visit today, the daughter noted that her mother was lethargic, confused, and unable to am- bulate with a walker. POC testing in the ED indicated the presence of multiple bacteria in the client’s urine and FSBG of 331 mg/dL (18.4 mmol/L). The client’s BP is currently 96/48 mm Hg. The nurse reviews the client assessment ndings and determines that the client most likely has which of the following conditions? Select all that apply. Urosepsis Delirium Dehydration ☐ COVID-19 ☐ DKA ☐ Transient ischemic attack Hyperglycemic hyperosmolar syndrome Multiple Response Select All That Apply Sample Question . THINKING SPACE
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Strategies for Student Success on the Next Generation NCLEX ® (NGN) Test Items 14 The nurse assesses a 53-year-old client whose partner brought the client to the ED with report of acute onset dyspnea and back pain that started about an hour ago. The client’s medical history includes DM type 2, obesity, hypertension, hypercholesteremia, and asthma. The client’s admission vital signs include: • Temperature = 98.8°F (37.1°C) • HR = 78 BPM and irregular • RR = 26 bpm and slightly labored • BP = 148/90 mm Hg • SpO 2 = 95% (on RA) The nurse reviews the client’s assessment data. Select 4 client nd- ings that are relevant and of immediate concern to the nurse Dyspnea Back pain ☐ Temperature ☐ History of obesity ☐ History of diabetes Tachypnea ☐ History of asthma Elevated BP Multiple Response Select N Sample Question . Remember: When reviewing cli- ent ndings, rst determine what is most relevant for that particu- lar client in the clinical scenario. Organize these ndings to deter- mine which data are consistent with specic client conditions or health problems. NGN TIP The nurse admits an 11-month-old infant who has possible bac- terial meningitis to the acute pediatric care unit. For each body system listed below, click or specify (with an X ) the po- tential nursing interventions that are appropriate for the client’s care. Each body system may support more than one potential intervention. Body System Potential Nursing Interventions Respiratory ☐ Incentive spirometer every 2 hours Oxygen therapy via nasal cannula ☐ Chest x-ray now and at bedtime Continuous pulse oximetry monitoring Droplet Precautions Neurologic Seizure Precautions ☐ Neurologic checks every day Cardiovascular ☐ Type and crossmatch for 2 units of packed red blood cells (PRBCs) Vital signs every hour Contact physician if temperature above 102.4°F (39.1°C) Begin IV cefotaxime infusion Blood cultures Multiple Response Grouping Sample Question . Rationale: e client’s new symptoms include dyspnea and back pain, which could indicate a possible MI and therefore are relevant in this clinical scenario. Women with an MI oen present with symptoms that dier from those in men, including having back or jaw pain. e client’s RR and BP are both elevated, but the temperature is normal. HR is within normal limits but is irregular. e medical history may help explain or predict the current client condition, but is not relevant at this time for planning nursing care. Other examples of questions or statements that could be part of a Multiple Response Select N test item with their associated cognitive skills include: ■ Select the three priority health problems that the client is experiencing. Analyze Cues ■ What are the five assessment findings that indicate the client is improving? Evaluate Outcomes ■ Select the four physician orders that the nurse would anticipate for this client. Take Action Multiple Response Grouping Item e Multiple Response Grouping test item is similar to the Multiple Response Select All at Apply item except that the options are presented in categories or by group in a table with a minimum of two columns and ve rows. Each category will have two to four options per row and require that at least one response option be selected. Sample Question 2.5 shows an example of this type of item to measure the clinical judgment cognitive skill of Generate Solutions for a pediatric client who has bacterial meningitis.
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