NCLEX Exam Versus Real World Nursing

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

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

Let’s see how someone using his or her real-world experience would approach this question:
(1)  “The roommate is never involved in identification of a client.”
(2)  “A confused client cannot be relied on for an accurate identification.”
3)  “Sounds reasonable. I have seen this done in some circumstances.”
(4)  “A picture? What picture? I’ve never seen a picture of a client in a chart!”
Possible conclusions drawn by this person would include: “OK, I’ve seen one nurse ask another for information so (3) must be the answer,” or “Well, maybe the client isn’t all that confused, so I’ll select (2).” 
According to nursing textbooks, asking another health care professional is not the correct way to identify a client. Many acute-care settings now include a photo of the client in the chart for just this type of situation. The correct answer to this question is (4). Many students reject this answer because there are rarely pictures of clients in the charts. Real-world experience doesn’t count, though; in this case, the client does have a picture in his chart.
The NCLEX-RN® exam is a standardized exam administered by NCSBN. Because the NCLEX-RN® exam is a national exam, students should be aware that in some parts of the country, nursing is practiced slightly differently. However, to ensure that the test is reflective of national trends, questions and answers are all carefully documented. The test makers ensure that the correct answers are documented in at least two standard nursing textbooks, or in one textbook and one nursing journal.

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

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

Practice Question

Let’s look at another practice question.

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

Let’s look at this using real-world logic.
(1)  “Place the client in restraints.” Yes, that is done in the real world.
(2)  “Leave the client in a room by himself until the tranquilizer takes effect.” Yes, that is done in the real world, but most students recognize that it is not the best answer.
(3)  “Assign a practical nurse to stay with the client and assess his condition.” Sounds good, but what if you don’t have enough staffing to assign an LPN/LVN to sit with this client?
(4)  “Ask the security guard to stay with the client.” Yes, in the real world, security is called when clients are agitated.
According to real-world logic, the correct answer must be (1) or (4). However, textbook theoretical nursing practice states that this client should not be left alone while in an agitated state. A professional should remain with the client. Therefore, the correct answer is (3).
Use your real-world experience to help you visualize the client described in the test question, but select your answers based on what is found in nursing textbooks.
Your nursing faculty has probably been conscientious about instructing you in the most up- to-date nursing practice. According to the National Council, the primary source for documenting correct answers is in nursing textbooks, and the most up-to-date practice might not always agree with the textbooks. When in doubt, always select the textbook answer!

Question Topics

During the exam you will encounter questions that will trick you into choosing the wrong order of care. Here are four areas that may cause confusion and how tackle them.

First Take Care of the Client, Then the Equipment

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

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

Laboratory Values

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

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

Medication Administration

An important function in providing safe and effective care to clients is the administration of medications. Because this is one of the responsibilities of a beginning practitioner, questions about medications are often an important part of the NCLEX-RN® exam. The nurse who is minimally competent is knowledgeable about medications and uses the “six rights” when administering medication.
In nursing school, most questions about medication followed the same pattern. You were told the client’s diagnosis and the name of the medication, and then were asked a question. Even if you didn’t know the information about the medication, sometimes you were able to select the correct answer by knowing the diagnosis.
The NCLEX-RN® exam does not give you any clues from the context of the question. The questions on this exam include the name of the medication, almost always identifying it by both trade and generic names. Most of the time, you will not be given the reason the client is receiving the medication.

Notify the Physician

Another behavior that commonly occurs in the real world is calling the physician. In nursing school you were encouraged to notify your instructor of changes in your client’s condition. Be very careful how you handle this on the NCLEX-RN® exam. More often than not, the answer choice that states “call the physician,” “contact the social worker,” or “refer to the chaplain” is the WRONG answer. Usually there is something you need to do first before you make that call. The NCLEX-RN® exam does not want to know what the physician is going to do. The NCLEX-RN® exam wants to know what you, the registered professional nurse, will do in a given situation.
Before you want to choose the answer choice that involves “call the physician,” look at the other answer choices very carefully. Make sure that there isn’t an answer that contains an assessment or action you should do before making the phone call. The test makers want to know what you would do in a situation, not what the doctor would do!
Expect to see real-world situations on your NCLEX-RN® exam, but make sure that you do not choose real-world answers! These strategies should help you use your previous nursing experience without encountering any pitfalls.