Saunders Comprehensive Review for the NCLEX-RN Examination 7th edition Silvestri eBook
C H A P T E R 1
The NCLEX-RN® Examination
The Pyramid to Success
Welcome to the Pyramid to Success
Saunders Comprehensive Review for the
SaundersComprehensive Reviewfor theNCLEX-RN® Examination
is specially designed to help you begin your successful
journey to the peak of the pyramid, becoming a
registered nurse. As you begin your journey, you will be
introduced to all of the important points regarding the
NCLEX-RN examination and the process of testing,
and to the unique and special tips regarding how to prepare
yourself for this important examination. You will
read what a nursing graduate who recently passed the
NCLEX-RN examination has to say about the test.
Important test-taking strategies are detailed. These
details will guide you in selecting the correct option or
assist you in selecting an answer to a question at which
you must guess.
Each unit in this book begins with the Pyramid to
Success. The Pyramid to Success addresses specific points
related to the NCLEX-RN examination. Client Needs as
identified in the test plan framework for the examination
are listed as well as learning objectives for the unit. Pyramid
Terms are keywords that are defined in the glossary
at the end of the book and set in color throughout each
chapter to direct your attention to significant points for
Throughout each chapter, you will find Pyramid
Point bullets that identify areas most likely to be tested
on the NCLEX-RN examination. Read each chapter, and
identify your strengths and areas that are in need of further
review. Test your strengths and abilities by taking all
practice tests provided in this book and on the accompanying
Evolve site. Be sure to read all of the rationales and
test-taking strategies. The rationale provides you with
significant information regarding the correct and incorrect
options. The test-taking strategy provides you with
the logical path to selecting the correct option. The
test-taking strategy also identifies the content area to
review, if required. The reference source and page number
are provided so that you can easily find the information
that you need to review. Each question is coded on
the basis of the Level of Cognitive Ability, the Client
Needs category, the Integrated Process, Priority Concepts,
and the nursing content area.
Saunders Q&A Review for the NCLEX-RN®
Following the completion of your comprehensive review
in this book, continue on your journey through the Pyramid
to Success with the companion book, Saunders
Q&A Review for the NCLEX-RN® Examination. This book
provides you with more than 6000 practice questions in
the multiple-choice and alternate item formats, including
audio and video questions. The book is designed
based on the NCLEX-RN examination test plan framework,
with a specific focus on Client Needs and Integrated
Processes. In addition, each practice question in
this book includes a Priority Nursing Tip, which provides
you with an important piece of information that
will be helpful to answer questions. Then, you will be
ready for HESI/Saunders Online Review for the NCLEXRN
® Examination. Additional products in Saunders Pyramid
to Success include Saunders Strategies for Test Success:
Passing Nursing School and the NCLEX® Exam and
Saunders Q&A Review Cards for the NCLEX-RN® Exam.
These products are described next.
HESI/Saunders Online Review for the
This product addresses all areas of the test plan identified
by the National Council of State Boards of Nursing
(NCSBN). The course contains a pretest that provides
feedback regarding your strengths and weaknesses and
generates an individualized study schedule in a calendar
format. Content review is in an outline format and
includes self-check practice questions and testlets (case
studies), figures and illustrations, a glossary, and animations
and videos. Numerous online exams are included.
There are 2500 practice questions; the types of questions
in this course include multiple-choice and alternate item
Saunders Strategies for Test Success: Passing
Nursing School and the NCLEX® Exam
This product focuses on the test-taking strategies that will
help you to pass your nursing examinations while in
nursing school and will prepare 2 you for the NCLEX-RN
examination. The chapters describe various test-taking
strategies and include sample questions that illustrate
how to use the strategies. Also included in this book is
information on cultural characteristics and practices,
pharmacology strategies, medication and intravenous
calculations, laboratory values, positioning guidelines,
and therapeutic diets. This book has more than 1200
practice questions, and each question provides a tip for
the beginning nursing student. The practice questions
reflect the framework and the content identified in the
NCLEX-RN test plan and include multiple-choice and
alternate item format questions, including audio and
Saunders Q&A Review Cards for the
This product is organized by content area and the framework
of the NCLEX-RN test plan. It provides you with
1200 unique practice test questions on portable and
easy-to-use cards. The cards have the question on the front
of the card, and the answer, rationale, and test-taking
strategy are on the back of the card. This product includes
multiple-choice questions and alternate item format
questions, including fill-in-the-blank, multiple-response,
ordered-response, figure, and chart/exhibit questions.
Saunders RNtertainment for the NCLEX-RN® Exam
RNtertainment: The NCLEX® Review Game, 2nd Edition
is a revolutionary board game that offers nursing students
a fun and challenging change of pace from standard
review options. 800 clinical questions and
scenarios cover all the major nursing categories on the
NCLEX® test plan—including Health Promotion and
Maintenance, Physiological Integrity, Psychosocial
Integrity, and Safe and Effective Care Environment. This
completely redesigned second edition also features new
alternate item formats, test-taking tips and test-taking
traps covering helpful test taking strategies and techniques,
and a rationales booklet that provides justification
for correct answers.
All products in the Saunders Pyramid to Success can
be obtained online by visiting http://elsevierhealth.com
or by calling 800-545-2522.
Let’s begin our journey through the Pyramid to
An important step in the Pyramid to Success is to
become as familiar as possible with the examination
process. Candidates facing the challenge of this examination
can experience significant anxiety. Knowingwhat
the examination is all about and knowing what you will
encounter during the process of testing will assist in alleviating
fear and anxiety. The information contained in
this chapter was obtained from the NCSBN Web site
(http://www.ncsbn.org) and from the NCSBN 2016 test
plan for the NCLEX-RN and includes some procedures
related to registering for the exam, testing procedures,
and the answers to the questions most commonly asked
by nursing students and graduates preparing to take the
NCLEX. You can obtain additional information regarding
the test and its development by accessing the NCSBN
Web site and clicking on the NCLEXExam tab or by writing
to the National Council of State Boards of Nursing,
111 East Wacker Drive, Suite 2900, Chicago, IL 60601.
You are encouraged to access the NCSBN Web site
because this site provides you with valuable information
about the NCLEX and other resources available to an
Computer Adaptive Testing
The acronym CAT stands for computer adaptive test,
which means that the examination is created as the
test-taker answers each question. All the test questions
are categorized on the basis of the test plan structure
and the level of difficulty of the question. As you answer
a question, the computer determines your competency
based on the answer you selected. If you selected a correct
answer, the computer scans the question bank and
selects a more difficult question. If you selected an incorrect
answer, the computer scans the question bank and
selects an easier question. This process continues until
all test plan requirements are met and a reliable passor-
fail decision is made.
When taking a CAT, once an answer is recorded, all
subsequent questions administered depend, to an
extent, on the answer selected for that question. Skipping
and returning to earlier questions are not compatible
with the logical methodology of a CAT. The inability
to skip questions or go back to change previous answers
will not be a disadvantage to you; you will not fall into
that “trap” of changing a correct answer to an incorrect
one with the CAT system.
If you are faced with a question that contains unfamiliar
content, you may need to guess at the answer.
There is no penalty for guessing but you need to make
an educated guess. With most of the questions, the
answer will be right there in front of you. If you need
to guess, use your nursing knowledge and clinical experiences
to their fullest extent and all of the test-taking
strategies you have practiced in this review program.
You do not need any computer experience to take this
examination. A keyboard tutorial is provided and
administered to all test-takers at the start of the examination.
The tutorial will instruct you on the use of the onscreen
optional calculator, the use of the mouse, and
how to record an answer. The tutorial provides instructions
on how to respond to all question types on this
examination. This tutorial is provided on the NCSBN
Web site, and you are encouraged to view the tutorial
CHAPTER 1 The NCLEX-RN® Examination 3
when you are preparing for the NCLEX examination. In
addition, at the testing site, a test administrator is present
to assist in explaining the use of the computer to ensure
your full understanding of how to proceed.
Development of the Test Plan
The test plan for the NCLEX-RN examination is developed
by the NCSBN. The examination is a national
examination; the NCSBN considers the legal scope of
nursing practice as governed by state laws and regulations,
including the Nurse Practice Act, and uses these
laws to define the areas on the examination that will
assess the competence of the test-taker for licensure.
The NCSBN also conducts an important study every
3 years, known as a practice analysis study, to determine
the framework for the test plan for the examination. The
participants in this study include newly licensed registered
nurses from all types of basic nursing education
programs. From a list of nursing care activities provided,
the participants are asked about the frequency and
importance of performing them in relation to client
safety and the setting in which they are performed. A
panel of content experts at the NCSBN analyzes the
results of the study and makes decisions regarding the
test plan framework. The results of this recently conducted
study provided the structure for the test plan
implemented in April 2016.
The content of the NCLEX-RN examination reflects the
activities identified in the practice analysis study conducted
by the NCSBN. The questions are written to
address Level of Cognitive Ability, Client Needs, and
Integrated Processes as identified in the test plan developed
by the NCSBN.
Level of Cognitive Ability
Levels of cognitive ability include knowledge, understanding,
applying, analyzing, synthesizing, evaluating,
and creating. The practice of nursing requires complex
thought processing and critical thinking in decision making.
Therefore, you will not encounter any knowledge or
understanding questions on the NCLEX. Questions on
this examination are written at the applying level or at
higher Levels of Cognitive Ability. Box 1-1 presents an
example of a question that requires you to apply data.
The NCSBN identifies a test plan framework based on
Client Needs, which includes 4 major categories. Some
of these categories are divided further into subcategories.
The Client Needs categories are Safe and Effective Care
Environment, Health Promotion and Maintenance,
Psychosocial Integrity, and Physiological Integrity
Safe and Effective Care Environment
The Safe and Effective Care Environment category
includes 2 subcategories: Management of Care, and
Safety and Infection Control. According to the NCSBN,
Management of Care (17% to 23% of questions)
addresses prioritizing content and content that will
ensure a safe care delivery setting to protect clients, families,
significant others, visitors, and health care personnel.
The NCSBN indicates that Safety and Infection
Control (9% to 15% of questions) addresses content
that will protect clients, families, significant others, visitors,
and health care personnel from health and environmental
hazards within health care facilities and in
community settings. Box 1-2 presents examples of questions
that address these 2 subcategories.
BOX 1-1 Level of Cognitive Ability: Applying
The nurse notes blanching, coolness, and edema at the
peripheral intravenous (IV) site. On the basis of these findings,
the nurse should implement which action?
1. Remove the IV.
2. Apply a warm compress.
3. Check for a blood return.
4. Measure the area of infiltration.
This question requires that you focus on the data in the question
and determine that the client is experiencing an infiltration.
Next, you need to consider the harmful effects of
infiltration and determine the action to implement. Because
infiltration can be damaging to the surrounding tissue, the
appropriate action is to remove the IV to prevent any further
TABLE 1-1 Client Needs Categories and Percentage
of Questions on the NCLEX-RN Examination
Client Needs Category
Safe and Effective Care Environment
Management of Care 17-23
Safety and Infection Control 9-15
Health Promotion and Maintenance 6-12
Psychosocial Integrity 6-12
Basic Care and Comfort 6-12
Pharmacological and Parenteral Therapies 12-18
Reduction of Risk Potential 9-15
Physiological Adaptation 11-17
4 UNIT I NCLEX-RN® Exam Preparation
Health Promotion and Maintenance
The Health Promotion and Maintenance category (6%
to 12% of questions) addresses the principles related
to growth and development. According to the NCSBN,
this Client Needs category also addresses content
required to assist the client, family members, and significant
others to prevent health problems; to recognize
alterations in health; and to develop health practices that
promote and support wellness. See Box 1-3 for an
example of a question in this Client Needs category.
The Psychosocial Integrity category (6% to 12% of questions)
addresses content required to promote and support
the ability of the client, client’s family, and
client’s significant other to cope, adapt, and problemsolve
during stressful events. The NCSBN also indicates
that this Client Needs category addresses the emotional,
mental, and social well-being of the client, family, or significant
other, and care for the client with an acute or
chronic mental illness. See Box 1-4 for an example of
a question in this Client Needs category.
The Physiological In tegrity category includes 4 subcategories:
Basic Care and Comfort, Pharmacological and
Parenteral Therapies, Reduction of Risk Potential, and
BOX 1-2 Safe and Effective Care Environment
Management of Care
The nurse has received the client assignment for the day.
Which client should the nurse assess first?
1. The client who needs to receive subcutaneous insulin
2. The client who has a nasogastric tube attached to intermittent
3. The client who is 2 days postoperative and is complaining
of incisional pain
4. The client who has a blood glucose level of 50 mg/dL
(2.8 mmol/L) and complaints of blurred vision
This question addresses the subcategory Management of
Care in the Client Needs categorySafe and Effective Care Environment.
Note the strategic word, first, so you need to establish
priorities by comparing the needs of each client and
deciding which need is urgent. The client described in the correct
option has a lowblood glucose level and symptoms reflective
of hypoglycemia. This client should be assessed first so
that treatment can be implemented. Although the clients in
options 1, 2, and 3 have needs that require assessment, their
assessments can wait until the client in the correct option is
Safety and Infection Control
The nurse prepares to care for a client on contact precautions
who has a hospital-acquired infection caused by methicillinresistant
Staphylococcus aureus (MRSA). The client has an
abdominal wound that requires irrigation and has a tracheostomy
attached to a mechanical ventilator, which requires frequent
suctioning. The nurse should assemble which
necessary protective items before entering the client’s room?
1. Gloves and gown
2. Gloves and face shield
3. Gloves, gown, and face shield
4. Gloves, gown, and shoe protectors
This question addresses the subcategory Safety and Infection
Control in the Client Needs category Safe and Effective Care
Environment. It addresses content related to protecting oneself
from contracting an infection and requires that you consider
the methods of possible transmission of infection,
based on the client’s condition. Because splashes of infective
material can occur during the wound irrigation or suctioning
of the tracheostomy, option 3 is correct.
BOX 1-3 Health Promotion and Maintenance
The nurse is choosing age-appropriate toys for a toddler.
Which toy is the best choice for this age?
2. Toy soldiers
3. Large stacking blocks
4. A card game with large pictures
This question addresses the Client Needs category Health
Promotion and Maintenance and specifically relates to the
principles of growth and development of a toddler. Note the
strategic word, best. Toddlers like to master activities independently,
such as stacking blocks. Because toddlers do not have
the developmental ability to determine what could be harmful,
toys that are safe need to be provided. A puzzle and toy soldiers
provide objects that can be placed in the mouth and
may be harmful for a toddler. A card game with large pictures
may require cooperative play, which is more appropriate for a
BOX 1-4 Psychosocial Integrity
A client with coronary artery disease has selected guided
imagery to help cope with psychological stress. Which client
statement indicates an understanding of this stress reduction
1. “This will help only if I play music at the same time.”
2. “This will work for me only if I am alone in a quiet area.”
3. “I need to do this only when I lie down in case I fall asleep.”
4. “The best thing about this is that I can use it anywhere,
This question addresses the Client Needs category Psychosocial
Integrity and the content addresses coping mechanisms.
Guided imagery involves the client creating an image in the
mind, concentrating on the image, and gradually becoming
less aware of the offending stimulus. It can be done anytime
and anywhere; some clients may use other relaxation techniques
or play music with it.
CHAPTER 1 The NCLEX-RN® Examination 5
Physiological Adaptation. The NCSBN describes these
subcategories as follows. Basic Care and Comfort (6%
to 12% of questions) addresses content for providing
comfort and assistance to the client in the performance
of activities of daily living. Pharmacological and Parenteral
Therapies (12% to 18% of questions) addresses
content for administering medications and parenteral
therapies such as intravenous therapies and parenteral
nutrition, and administering blood and blood products.
Reduction of Risk Potential (9% to 15% of questions)
addresses content for preventing complications or
health problems related to the client’s condition or
any prescribed treatments or procedures. Physiological
Adaptation (11% to 17% of questions) addresses
content for providing care to clients with acute, chronic,
or life-threatening conditions. See Box 1-5 for examples
of questions in this Client Needs category.
The NCSBN identifies 5 processes in the test plan that are
fundamental to the practice of nursing. These processes
are incorporated throughout the major categories of Client
Needs. The Integrated Process subcategories are Caring,
Communication and Documentation, Nursing
BOX 1-5 Physiological Integrity
Basic Care and Comfort
Aclient with Parkinson’s disease develops akinesia while ambulating,
increasing the risk for falls. Which suggestion should the
nurse provide to the client to alleviate this problem?
1. Use a wheelchair to move around.
2. Stand erect and use a cane to ambulate.
3. Keep the feet close together while ambulating and use a
4. Consciously think about walking over imaginary lines on the
This question addresses the subcategory Basic Care and Comfort
in the Client Needs category Physiological Integrity, and
addresses client mobility and promoting assistance in an activityof
dailyliving to maintain safety. Clients with Parkinson’s disease
can develop bradykinesia (slow movement) or akinesia
(freezing or no movement). Having these clients imagine lines
on the floor to walk over can keep them moving forward while
Pharmacological and Parenteral Therapies
The nurse monitors a client receiving digoxin for which early
manifestation of digoxin toxicity?
2. Facial pain
4. Yellow color perception
This question addresses the subcategory Pharmacological and
Parenteral Therapies in the Client Needs category Physiological
Integrity. Note the strategic word, early. Digoxin is a cardiac glycoside
that is used to manage and treat heart failure and to control
ventricular rates in clients with atrial fibrillation. The most
common early manifestations of toxicity include gastrointestinal
disturbances such as anorexia, nausea, and vomiting. Neurological
abnormalities can also occur early and include fatigue,
headache, depression, weakness, drowsiness, confusion, and
nightmares. Facial pain, personality changes, and ocular disturbances
(photophobia, diplopia, light flashes, halos around
bright objects, yellow or green color perception) are also signs
of toxicity, but are not early signs.
Reduction of Risk Potential
A magnetic resonance imaging (MRI) study is prescribed for a
client with a suspected brain tumor. The nurse should implement
which action to prepare the client for this test?
1. Shave the groin for insertion of a femoral catheter.
2. Remove all metal-containing objects from the client.
3. Keep the client NPO (nilper os; nothing bymouth) for 6 hours
before the test.
4. Instruct the client in inhalation techniques for the administration
of the radioisotope.
This question addresses the subcategory Reduction of Risk
Potential in the Client Needs category Physiological Integrity,
and the nurse’s responsibilities in preparing the client for the
diagnostic test. In anMRI study, radiofrequencypulses in a magnetic
field are converted into pictures. All metal objects, such as
rings, bracelets, hairpins, and watches, should be removed. In
addition, a historyshould be taken to ascertain whether the client
has any internal metallic devices, such as orthopedic hardware,
pacemakers, or shrapnel. NPO status is not necessary for an
MRI study of the head. The groin may be shaved for an angiogram,
and inhalation of the radioisotope may be prescribed with
other types ofscans but is not a part of the procedures for anMRI.
A client with renal insufficiency has a magnesium level of
3.5 mEq/L (1.75 mmol/L). On the basis of this laboratory result,
the nurse interprets which sign as significant?
4. Physical hyperactivity
This question addresses the subcategory Physiological Adaptation
in the Client Needs category Physiological Integrity.
It addresses an alteration in body systems. The normal
magnesium level is 1.5 to 2.5 mEq/L(0.75 to 1.25 mmol/L).
A magnesium level of 3.5 mEq/ L (1.75 mmol/ L) indicates hypermagnesemia.
Neurological manifestations begin to occur when
magnesium levels are elevated and are noted as symptoms of
neurological depression, such as drowsiness, sedation, lethargy,
respiratory depression, muscle weakness, and areflexia.
Bradycardia and hypotension also occur.
6 UNIT I NCLEX-RN® Exam Preparation
Process (Assessment,Analysis, Planning, Implementation,
and Evaluation), Culture and Spirituality, and Teaching
and Learning. See Box 1-6 for an example of a question
that incorporates the Integrated Process of Caring.
Types of Questions on the Examination
The types of questions that may be administered on the
examination include multiple-choice; fill-in-the-blank;
multiple-response; ordered-response (also known as drag
and drop); questions that contain a figure, chart/exhibit,
or graphic option item; and audio or video item formats.
Some questions may require you to use the mouse and
cursor on the computer. For example, you may be presented
with a picture that displays the arterial vessels of
an adult client. In this picture, you may be asked to “point
and click” (using themouse) on the area (hot spot) where
the dorsalis pedis pulse could be felt. In all types of questions,
the answer is scored as either right or wrong. Credit
is not given for a partially correct answer. In addition, all
question types may include pictures, graphics, tables,
charts, sound, or video. The NCSBN provides specific
directions for you to follow with all question types to
guide you in your process of testing. Be sure to read these
directions as they appear on the computer screen. Examples
of some of these types of questions are noted in this
chapter. All question types are provided in this book and
on the accompanying Evolve site.
Many of the questions that you will be asked to answer
will be in the multiple-choice format. These questions
provide you with data about a client situation and 4
answers, or options.
Fill-in-the-blank questions may ask you to perform a
medication calculation, determine an intravenous flow
rate, or calculate an intake or output record on a client.
You will need to type only a number (your answer) in
the answer box. If the question requires rounding the
answer, this needs to be performed at the end of the calculation.
The rules for rounding an answer are described
in the tutorial provided by the NCSBN, and are also provided
in the specific question on the computer screen. In
addition, you must type in a decimal point if necessary.
See Box 1-7 for an example.
For a multiple-response question, you will be asked to
select or check all of the options, such as nursing interventions,
that relate to the information in the question. In
these question types, there may be 2 or more correct
answers. No partial credit is given for correct selections.
You need to do exactly as the question asks, which will
be to select all of the options that apply. See Box 1-8 for
In this type of question, you will be asked to use the computer
mouse to drag and drop your nursing actions in
order of priority. Information will be presented in a
question and, based on the data, you need to determine
what you will do first, second, third, and so forth. The
unordered options will be located in boxes on the left
side of the screen, and you need to move all options
in order of priority to ordered-response boxes on the
BOX 1-6 Integrated Processes
A client is scheduled for angioplasty. The client says to the
nurse, “I’m so afraid that it will hurt and will make me worse
off than I am.” Which response by the nurse is therapeutic?
1. “Can you tell me what you understand about the
2. “Your fears are a sign that you really should have this
3. “Those are very normal fears, but please be assured that
everything will be okay.”
4. “Try not to worry. This is a well-known and easy procedure
for the health care provider.”
This question addresses the subcategory Caring in the category
Integrated Processes. The correct option is a therapeutic
communication technique that explores the client’s feelings,
determines the level of client understanding about the procedure,
and displays caring. Option 2 demeans the client and
does not encourage further sharing by the client. Option 3
does not address the client’s fears, provides false reassurance,
and puts the client’s feelings on hold. Option 4 diminishes the
client’s feelings bydirecting attention awayfrom the client and
toward the health care provider’s importance.