Saunders Comprehensive Review for the NCLEX-RN® Examination (2022)
Saunders Comprehensive Review for the NCLEX-RN® Examination (2022) simplifies exam prep with well-structured content and practice questions.
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Linda Anne Silvestri, PhD, RN, FAAN
Nursing Instructor
University of Nevada, Las Vegas
Las Vegas, Nevada
President and Owner
Nursing Reviews, Inc.
Henderson, Nevada
Director and Owner
Professional Nursing Seminars, Inc.
Henderson, Nevada
Elsevier
Next Generation NCLEX® (NGN) Consultant and
Subject Matter Expert
Angela E. Silvestri, PhD, APRN, FNP-BC,
CNE
Associate Professor and BSN Program Director
University of Nevada, Las Vegas
Las Vegas, Nevada
President
Clinical Judgment Test-Taking Strategy Creator
Nurse Prep, LLC
Henderson, Nevada
Elsevier
Next Generation NCLEX® (NGN) Subject Matter Expert
Associate Editor
Jessica Grimm, DNP, APRN, ACNP-BC,
CNE
Associate Professor of Nursing
Touro University Nevada
Henderson, Nevada
Assistant Professor of Anesthesia and
Perioperative Medicine
Oregon Health State University
Portland, Oregon
NCLEX-RN®
examination
S A U N D E R S
COMPREHENSIVE REVIEW for the
E D I T I O N
9
Nursing Instructor
University of Nevada, Las Vegas
Las Vegas, Nevada
President and Owner
Nursing Reviews, Inc.
Henderson, Nevada
Director and Owner
Professional Nursing Seminars, Inc.
Henderson, Nevada
Elsevier
Next Generation NCLEX® (NGN) Consultant and
Subject Matter Expert
Angela E. Silvestri, PhD, APRN, FNP-BC,
CNE
Associate Professor and BSN Program Director
University of Nevada, Las Vegas
Las Vegas, Nevada
President
Clinical Judgment Test-Taking Strategy Creator
Nurse Prep, LLC
Henderson, Nevada
Elsevier
Next Generation NCLEX® (NGN) Subject Matter Expert
Associate Editor
Jessica Grimm, DNP, APRN, ACNP-BC,
CNE
Associate Professor of Nursing
Touro University Nevada
Henderson, Nevada
Assistant Professor of Anesthesia and
Perioperative Medicine
Oregon Health State University
Portland, Oregon
NCLEX-RN®
examination
S A U N D E R S
COMPREHENSIVE REVIEW for the
E D I T I O N
9
Loading page 4...
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
SAUNDERS COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION,
NINTH EDITION ISBN: 978-0-323-79530-2
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.
NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State
Boards of Nursing, Inc.
Previous editions copyrighted 2020, 2017, 2014, 2012, and 2009.
Content Strategist: Heather Bays-Petrovic
Senior Content Development Specialists: Laura Goodrich and Rebecca Leenhouts
Publishing Services Manager: Julie Eddy
Senior Project Manager: Cindy Thoms
Senior Book Designer: Margaret Reid
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
3251 Riverport Lane
St. Louis, Missouri 63043
SAUNDERS COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION,
NINTH EDITION ISBN: 978-0-323-79530-2
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.
NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State
Boards of Nursing, Inc.
Previous editions copyrighted 2020, 2017, 2014, 2012, and 2009.
Content Strategist: Heather Bays-Petrovic
Senior Content Development Specialists: Laura Goodrich and Rebecca Leenhouts
Publishing Services Manager: Julie Eddy
Senior Project Manager: Cindy Thoms
Senior Book Designer: Margaret Reid
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Loading page 5...
iii
Unit I
NCLEX-RN® Exam Preparation, 1
1 Clinical Judgment and the Next Generation
NCLEX (NGN)-RN® Examination, 2
2 Self-Efcacy and Pathways to Success, 17
3 The NCLEX-RN® Examination from a Graduate’s
Perspective, 22
4 Clinical Judgment and Test-Taking
Strategies, 24
Unit II
Professional Standards in Nursing, 38
5 Population Health Nursing, 40
6 Ethical and Legal Issues, 53
7 Prioritizing Client Care: Leadership, Delegation,
and Emergency Response Planning, 68
Unit III
Foundations of Care, 85
8 Fluids and Electrolytes, 88
9 Acid-Base Balance, 106
Vital Signs and Laboratory Reference
Intervals, 116
11 Nutrition, 132
12 Health and Physical Assessment of the Adult
Client, 143
13 Safety and Infection Control, 166
14 Medication Administration and Intravenous
Therapies, 178
15 Perioperative Nursing Care, 189
16 Hygiene, Mobility, and Skin Integrity, 204
17 Urinary and Bowel Elimination, 218
Unit IV
Growth and Development Across
the Life Span, 234
18 Theories of Growth and Development, 236
19 Growth, Development, and Stages of Life, 244
20 Care of the Older Client, 266
Unit V
Maternity Nursing, 275
21 Reproductive System, 277
22 Prenatal Period, 285
23 Risk Conditions Related to Pregnancy, 300
24 Labor and Birth, 323
25 Problems with Labor and Birth, 336
26 Postpartum Period, 343
27 Postpartum Complications, 350
28 Care of the Newborn, 358
29 Maternity and Newborn Medications, 380
Unit VI
Pediatric Nursing, 391
30 Integumentary Problems, 392
31 Hematological Problems, 399
32 Oncological Problems, 406
33 Metabolic and Endocrine Problems, 416
34 Gastrointestinal Problems, 425
35 Eye, Ear, and Throat Problems, 444
36 Respiratory Problems, 451
37 Cardiovascular Problems, 467
38 Renal and Genitourinary Problems, 479
39 Neurological and Cognitive Problems, 487
40 Musculoskeletal Problems, 498
41 Immune Problems and Infectious Diseases, 507
42 Pediatric Medication Administration and
Calculations, 520
Contents
Unit I
NCLEX-RN® Exam Preparation, 1
1 Clinical Judgment and the Next Generation
NCLEX (NGN)-RN® Examination, 2
2 Self-Efcacy and Pathways to Success, 17
3 The NCLEX-RN® Examination from a Graduate’s
Perspective, 22
4 Clinical Judgment and Test-Taking
Strategies, 24
Unit II
Professional Standards in Nursing, 38
5 Population Health Nursing, 40
6 Ethical and Legal Issues, 53
7 Prioritizing Client Care: Leadership, Delegation,
and Emergency Response Planning, 68
Unit III
Foundations of Care, 85
8 Fluids and Electrolytes, 88
9 Acid-Base Balance, 106
Vital Signs and Laboratory Reference
Intervals, 116
11 Nutrition, 132
12 Health and Physical Assessment of the Adult
Client, 143
13 Safety and Infection Control, 166
14 Medication Administration and Intravenous
Therapies, 178
15 Perioperative Nursing Care, 189
16 Hygiene, Mobility, and Skin Integrity, 204
17 Urinary and Bowel Elimination, 218
Unit IV
Growth and Development Across
the Life Span, 234
18 Theories of Growth and Development, 236
19 Growth, Development, and Stages of Life, 244
20 Care of the Older Client, 266
Unit V
Maternity Nursing, 275
21 Reproductive System, 277
22 Prenatal Period, 285
23 Risk Conditions Related to Pregnancy, 300
24 Labor and Birth, 323
25 Problems with Labor and Birth, 336
26 Postpartum Period, 343
27 Postpartum Complications, 350
28 Care of the Newborn, 358
29 Maternity and Newborn Medications, 380
Unit VI
Pediatric Nursing, 391
30 Integumentary Problems, 392
31 Hematological Problems, 399
32 Oncological Problems, 406
33 Metabolic and Endocrine Problems, 416
34 Gastrointestinal Problems, 425
35 Eye, Ear, and Throat Problems, 444
36 Respiratory Problems, 451
37 Cardiovascular Problems, 467
38 Renal and Genitourinary Problems, 479
39 Neurological and Cognitive Problems, 487
40 Musculoskeletal Problems, 498
41 Immune Problems and Infectious Diseases, 507
42 Pediatric Medication Administration and
Calculations, 520
Contents
Loading page 6...
Contentsiv
Unit VII
Integumentary Problems of the Adult
Client, 527
43 Integumentary Problems, 528
44 Integumentary Medications, 538
Unit VIII
Oncological and Hematological
Problems of the Adult Client, 547
45 Oncological and Hematological Problems, 549
46 Oncological and Hematological
Medications, 587
Unit IX
Endocrine Problems of the Adult Client, 598
47 Endocrine Problems, 599
48 Endocrine Medications, 626
Unit X
Gastrointestinal Problems of the Adult
Client, 641
49 Gastrointestinal Problems, 643
50 Gastrointestinal Medications, 671
Unit XI
Respiratory Problems of the Adult
Client, 679
51 Respiratory Problems, 680
52 Respiratory Medications, 701
Unit XII
Cardiovascular Problems of the Adult
Client, 719
53 Cardiovascular Problems, 720
54 Cardiovascular Medications, 760
Unit XIII
Renal and Urinary Problems of the Adult
Client, 778
55 Renal and Urinary Problems, 779
56 Renal and Urinary Medications, 811
Unit XIV
Eye and Ear Problems of the Adult
Client, 821
57 Eye and Ear Problems, 822
58 Eye and Ear Medications, 842
Unit XV
Neurological Problems of the Adult
Client, 852
59 Neurological Problems, 853
60 Neurological Medications, 877
Unit XVI
Musculoskeletal Problems of the Adult
Client, 888
61 Musculoskeletal Problems, 889
62 Musculoskeletal Medications, 910
Unit XVII
Immune Problems of the Adult
Client, 918
63 Immune Problems, 919
64 Immune Medications, 933
Unit XVIII
Mental Health Problems of the Adult
Client, 940
65 Foundations of Psychiatric Mental Health
Nursing, 941
66 Mental Health Problems, 954
67 Addictions, 975
68 Crisis Theory and Intervention, 987
69 Psychotherapeutic Medications, 1001
Unit XIX
Complex Care, 1015
70 Complex Care, 1017
References, 1088
Index, 1090
Unit VII
Integumentary Problems of the Adult
Client, 527
43 Integumentary Problems, 528
44 Integumentary Medications, 538
Unit VIII
Oncological and Hematological
Problems of the Adult Client, 547
45 Oncological and Hematological Problems, 549
46 Oncological and Hematological
Medications, 587
Unit IX
Endocrine Problems of the Adult Client, 598
47 Endocrine Problems, 599
48 Endocrine Medications, 626
Unit X
Gastrointestinal Problems of the Adult
Client, 641
49 Gastrointestinal Problems, 643
50 Gastrointestinal Medications, 671
Unit XI
Respiratory Problems of the Adult
Client, 679
51 Respiratory Problems, 680
52 Respiratory Medications, 701
Unit XII
Cardiovascular Problems of the Adult
Client, 719
53 Cardiovascular Problems, 720
54 Cardiovascular Medications, 760
Unit XIII
Renal and Urinary Problems of the Adult
Client, 778
55 Renal and Urinary Problems, 779
56 Renal and Urinary Medications, 811
Unit XIV
Eye and Ear Problems of the Adult
Client, 821
57 Eye and Ear Problems, 822
58 Eye and Ear Medications, 842
Unit XV
Neurological Problems of the Adult
Client, 852
59 Neurological Problems, 853
60 Neurological Medications, 877
Unit XVI
Musculoskeletal Problems of the Adult
Client, 888
61 Musculoskeletal Problems, 889
62 Musculoskeletal Medications, 910
Unit XVII
Immune Problems of the Adult
Client, 918
63 Immune Problems, 919
64 Immune Medications, 933
Unit XVIII
Mental Health Problems of the Adult
Client, 940
65 Foundations of Psychiatric Mental Health
Nursing, 941
66 Mental Health Problems, 954
67 Addictions, 975
68 Crisis Theory and Intervention, 987
69 Psychotherapeutic Medications, 1001
Unit XIX
Complex Care, 1015
70 Complex Care, 1017
References, 1088
Index, 1090
Loading page 7...
In loving memory of my parents—
To my mother, Frances Mary, and my father, Arnold Lawrence,
who taught me to always love, care, and be the best that I could be.
My memories of their love, support, and words of encouragement will remain in my heart forever!
Linda Anne Silvestri
To my parents, Mary Elizabeth and Lawrence Peter,
who have instilled in me the values of working hard and being seless,
and who have been my support system as I pursue my professional goals
and life aspirations. My success thus far would not have been possible without them.
From the bottom of my heart, thank you, Mom & Dad!
Angela Elizabeth Silvestri
To my mother, Frances Mary, and my father, Arnold Lawrence,
who taught me to always love, care, and be the best that I could be.
My memories of their love, support, and words of encouragement will remain in my heart forever!
Linda Anne Silvestri
To my parents, Mary Elizabeth and Lawrence Peter,
who have instilled in me the values of working hard and being seless,
and who have been my support system as I pursue my professional goals
and life aspirations. My success thus far would not have been possible without them.
From the bottom of my heart, thank you, Mom & Dad!
Angela Elizabeth Silvestri
Loading page 8...
vi
To All Future Registered Nurses,
Congratulations to you!
You should be very proud and pleased with yourself on your most recent well-
deserved accomplishment of completing your nursing program to become a
registered nurse. We know that you have worked very hard to become suc-
cessful and that you have proven to yourself that indeed you can achieve your
goals.
In our opinion, you are about to enter the most wonderful and rewarding
profession that exists. Your willingness, desire, and ability to assist those who
need nursing care will bring great satisfaction to your life. In the profession
of nursing, your learning will be a lifelong process. This aspect of the profes-
sion makes it stimulating and dynamic. Your learning process will continue to
expand and grow as the profession continues to evolve. Your next very impor-
tant endeavor will be the learning process involved to achieve success in your
examination to become a registered nurse.
We are excited and pleased to be able to provide you with the Saunders Pyramid
to Success products, which will help you prepare for your next important pro-
fessional goal, becoming a registered nurse. We want to thank all of our former
and current nursing students whom we have assisted in their studies for the
NCLEX-RN® examination for their willingness to offer ideas regarding their
needs in preparing for licensure. Student ideas have certainly added a special
uniqueness to all of the products available in the Saunders Pyramid to Success.
Saunders Pyramid to Success products provide you with everything that you
need to ready yourself for the NCLEX-RN examination. These products include
material that is required for the NCLEX-RN examination for all nursing stu-
dents regardless of educational background, specic strengths, areas in need of
improvement, or clinical experience during the nursing program.
So let’s get started and begin our journey through the Saunders Pyramid to
Success, and welcome to the wonderful profession of nursing!
Sincerely,
Dr. Linda Anne Silvestri and Dr. Angela Elizabeth Silvestri
To All Future Registered Nurses,
Congratulations to you!
You should be very proud and pleased with yourself on your most recent well-
deserved accomplishment of completing your nursing program to become a
registered nurse. We know that you have worked very hard to become suc-
cessful and that you have proven to yourself that indeed you can achieve your
goals.
In our opinion, you are about to enter the most wonderful and rewarding
profession that exists. Your willingness, desire, and ability to assist those who
need nursing care will bring great satisfaction to your life. In the profession
of nursing, your learning will be a lifelong process. This aspect of the profes-
sion makes it stimulating and dynamic. Your learning process will continue to
expand and grow as the profession continues to evolve. Your next very impor-
tant endeavor will be the learning process involved to achieve success in your
examination to become a registered nurse.
We are excited and pleased to be able to provide you with the Saunders Pyramid
to Success products, which will help you prepare for your next important pro-
fessional goal, becoming a registered nurse. We want to thank all of our former
and current nursing students whom we have assisted in their studies for the
NCLEX-RN® examination for their willingness to offer ideas regarding their
needs in preparing for licensure. Student ideas have certainly added a special
uniqueness to all of the products available in the Saunders Pyramid to Success.
Saunders Pyramid to Success products provide you with everything that you
need to ready yourself for the NCLEX-RN examination. These products include
material that is required for the NCLEX-RN examination for all nursing stu-
dents regardless of educational background, specic strengths, areas in need of
improvement, or clinical experience during the nursing program.
So let’s get started and begin our journey through the Saunders Pyramid to
Success, and welcome to the wonderful profession of nursing!
Sincerely,
Dr. Linda Anne Silvestri and Dr. Angela Elizabeth Silvestri
Loading page 9...
vii
Linda Anne Silvestri,
PhD, RN, FAAN
Linda is a well-known
nurse educator, entre-
preneur, and philanthro-
pist whose professional
aspirations focus on
assisting nursing students
to become successful. She
has been teaching at all
levels of nursing education for many years. Linda is cur-
rently a nursing instructor at the University of Nevada,
Las Vegas (UNLV). She earned her PhD in nursing from
UNLV and conducted research on self-efcacy and the
predictors of NCLEX® success. Her research ndings are
published in the Journal of Nursing Education and Prac-
tice. 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. And in
2010, she received the School of Nursing’s Certicate
of Recognition for Outstanding PhD Student. Linda is
a member of several national nursing organizations,
including the Honor Society of Nursing, Sigma Theta
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 the national and international levels. She
also serves as an Elsevier Subject Matter Expert for the
Next Generation NCLEX® (NGN), and has presented
numerous webinars on NCLEX® preparation and suc-
cess. Dr. Silvestri is the President and Owner of Nursing
Reviews, Inc., and the Director and Owner of Profes-
sional Nursing Seminars, Inc. Both companies are dedi-
cated 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 administrative
roles for the last 10 years at
all levels of nursing education. She has experience teach-
ing in both classroom and clinical settings and in working
with graduate students on their culminating projects and
research dissertations. She currently serves as the Program
Director for the undergraduate BSN program at the Uni-
versity of Nevada, Las Vegas (UNLV). Dr. Silvestri is a suc-
cessful Elsevier author of numerous best-selling NCLEX®
preparation resources on the national and international
levels. She also serves as an Elsevier Subject Matter Expert
for the Next Generation NCLEX® (NGN). Angela earned
a bachelor’s in Nursing and in Sociology from Salve
Regina University in Newport, Rhode Island; she earned
her master’s degree with a focus in nursing education and
her 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 Practitio-
ner. She is a Scholar in Sigma Theta Tau’s New Academic
Leadership Academy. She works with faculty, staff, and
students on managing primary and episodic health care
needs at UNLV’s Student Wellness Center and Faculty and
Staff Treatment Center as a Family Nurse Practitioner. Dr.
Silvestri is passionate about college students’ success. She
is an expert in creating clinical judgment test-taking strat-
egies for NGN items. This passion also comes through
in her work at UNLV, where she teaches leadership and
licensure exam preparation, and in the publication of her
research and best-selling licensure exam review resources.
About the Authors
Linda Anne Silvestri,
PhD, RN, FAAN
Linda is a well-known
nurse educator, entre-
preneur, and philanthro-
pist whose professional
aspirations focus on
assisting nursing students
to become successful. She
has been teaching at all
levels of nursing education for many years. Linda is cur-
rently a nursing instructor at the University of Nevada,
Las Vegas (UNLV). She earned her PhD in nursing from
UNLV and conducted research on self-efcacy and the
predictors of NCLEX® success. Her research ndings are
published in the Journal of Nursing Education and Prac-
tice. 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. And in
2010, she received the School of Nursing’s Certicate
of Recognition for Outstanding PhD Student. Linda is
a member of several national nursing organizations,
including the Honor Society of Nursing, Sigma Theta
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 the national and international levels. She
also serves as an Elsevier Subject Matter Expert for the
Next Generation NCLEX® (NGN), and has presented
numerous webinars on NCLEX® preparation and suc-
cess. Dr. Silvestri is the President and Owner of Nursing
Reviews, Inc., and the Director and Owner of Profes-
sional Nursing Seminars, Inc. Both companies are dedi-
cated 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 administrative
roles for the last 10 years at
all levels of nursing education. She has experience teach-
ing in both classroom and clinical settings and in working
with graduate students on their culminating projects and
research dissertations. She currently serves as the Program
Director for the undergraduate BSN program at the Uni-
versity of Nevada, Las Vegas (UNLV). Dr. Silvestri is a suc-
cessful Elsevier author of numerous best-selling NCLEX®
preparation resources on the national and international
levels. She also serves as an Elsevier Subject Matter Expert
for the Next Generation NCLEX® (NGN). Angela earned
a bachelor’s in Nursing and in Sociology from Salve
Regina University in Newport, Rhode Island; she earned
her master’s degree with a focus in nursing education and
her 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 Practitio-
ner. She is a Scholar in Sigma Theta Tau’s New Academic
Leadership Academy. She works with faculty, staff, and
students on managing primary and episodic health care
needs at UNLV’s Student Wellness Center and Faculty and
Staff Treatment Center as a Family Nurse Practitioner. Dr.
Silvestri is passionate about college students’ success. She
is an expert in creating clinical judgment test-taking strat-
egies for NGN items. This passion also comes through
in her work at UNLV, where she teaches leadership and
licensure exam preparation, and in the publication of her
research and best-selling licensure exam review resources.
About the Authors
Loading page 10...
viii
Rossybel Aberle, RN, BSN
Graduate
University of Nevada, Las Vegas
Las Vegas, Nevada
Sarah R. Jean Baptiste, MS, PA-C
Physician Assistant
Oregon Health Science University
Portland, Oregon
Esmeralda Araceli Clark, MSN, APRN, FNP-BC
Lecturer
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Eileen H. Gray, RN, DNP, CPNP
Nursing Instructor
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Jessica Grimm, DNP, APRN, ACNP-BC, CNE
Associate Professor of Nursing
Touro University Nevada
Henderson, Nevada;
Assistant Professor of Anesthesia and Perioperative Medicine
Oregon Health State University
Portland, Oregon
James Guilbault, PharmD, BS, RPh
Pharmacy Manager and Clinical Staff
Pharmacist
Walgreens Pharmacy, Mercy Medical
Center, MCPHS University
Springeld, Massachusetts
Debra Hagler, PhD, RN, aCNS-BC, cNE, CHSE,
ANEF, FAAN
Clinical Professor
Edson College of Nursing and Health Innovation
Arizona State University
Phoenix, Arizona
Diana Rabbani Hagler, MSN-Ed, RN, CCRN
TeleHealth ICU RN
Banner Health, Grand Canyon University,
Maricopa Community Colleges
Adjunct Faculty
Phoenix, Arizona
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.
Michael Johnson, PhD, RN, PMH-BC, CNE
Director of Clinical Affairs and Associate Professor
School of Nursing
Nevada State College
Henderson, Nevada
Erica Shae Lee, MSN-Ed, RN
Associate Program Director
Prelicensure Nursing
Arizona State University
Phoenix, Arizona
Necole Leland, DNP, RN, PNP, CPN
Assistant Professor
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Lisa Nicholas, MSN, RN
Lecturer, Clinical Instructor
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Contributors
Rossybel Aberle, RN, BSN
Graduate
University of Nevada, Las Vegas
Las Vegas, Nevada
Sarah R. Jean Baptiste, MS, PA-C
Physician Assistant
Oregon Health Science University
Portland, Oregon
Esmeralda Araceli Clark, MSN, APRN, FNP-BC
Lecturer
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Eileen H. Gray, RN, DNP, CPNP
Nursing Instructor
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Jessica Grimm, DNP, APRN, ACNP-BC, CNE
Associate Professor of Nursing
Touro University Nevada
Henderson, Nevada;
Assistant Professor of Anesthesia and Perioperative Medicine
Oregon Health State University
Portland, Oregon
James Guilbault, PharmD, BS, RPh
Pharmacy Manager and Clinical Staff
Pharmacist
Walgreens Pharmacy, Mercy Medical
Center, MCPHS University
Springeld, Massachusetts
Debra Hagler, PhD, RN, aCNS-BC, cNE, CHSE,
ANEF, FAAN
Clinical Professor
Edson College of Nursing and Health Innovation
Arizona State University
Phoenix, Arizona
Diana Rabbani Hagler, MSN-Ed, RN, CCRN
TeleHealth ICU RN
Banner Health, Grand Canyon University,
Maricopa Community Colleges
Adjunct Faculty
Phoenix, Arizona
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.
Michael Johnson, PhD, RN, PMH-BC, CNE
Director of Clinical Affairs and Associate Professor
School of Nursing
Nevada State College
Henderson, Nevada
Erica Shae Lee, MSN-Ed, RN
Associate Program Director
Prelicensure Nursing
Arizona State University
Phoenix, Arizona
Necole Leland, DNP, RN, PNP, CPN
Assistant Professor
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Lisa Nicholas, MSN, RN
Lecturer, Clinical Instructor
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Contributors
Loading page 11...
Contributors ix
Karen L. Petersen, MSN-L, RN, MNN
Nursing Faculty
Paradise Valley Community College
Phoenix, Arizona
David Petersen, MSN-Ed, RN
Visiting Professor
School of Nursing
Chamberlain University
Phoenix, Arizona
Katherine M. Silvestri, MSN, APRN, FNP-BC
Editorial and Reviewer Consultant
Nursing Reviews, Inc.
Henderson, Nevada
Margaret Trnka, MSN, RN
Lecturer, Clinical Instructor
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Laurent W. Valliere, BS, DD
Vice President
Marketing
Nursing Reviews, Inc.
Henderson, Nevada
Janelle Willis, MSN, APRN, CNE
Lecturer, Clinical Instructor
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Karen L. Petersen, MSN-L, RN, MNN
Nursing Faculty
Paradise Valley Community College
Phoenix, Arizona
David Petersen, MSN-Ed, RN
Visiting Professor
School of Nursing
Chamberlain University
Phoenix, Arizona
Katherine M. Silvestri, MSN, APRN, FNP-BC
Editorial and Reviewer Consultant
Nursing Reviews, Inc.
Henderson, Nevada
Margaret Trnka, MSN, RN
Lecturer, Clinical Instructor
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Laurent W. Valliere, BS, DD
Vice President
Marketing
Nursing Reviews, Inc.
Henderson, Nevada
Janelle Willis, MSN, APRN, CNE
Lecturer, Clinical Instructor
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Loading page 12...
x
Emily Brown, MSN, APRN, FNP-BC
Family Nurse Practitioner
University Medical Center
Las Vegas, Nevada
Alena Grewal, MSN, APRN, FNP-BC
Assistant Professor of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Jessica Grimm, DNP, APRN, ACNP-BC, CNE
Associate Professor of Nursing
Touro University Nevada
Henderson, Nevada;
Assistant Professor of Anesthesia and Perioperative Medicine
Oregon Health State University
Portland, Oregon
James Guilbault, PharmD, BS, RPh
Pharmacy Manager and Clinical Staff Pharmacist
Walgreens Pharmacy, Mercy Medical Center,
MCPHS University
Springeld, Massachusetts
Debra Hagler, PhD, RN, aCNS-BC, cNE, CHSE, ANEF,
FAAN
Clinical Professor
Edson College of Nursing and Health Innovation
Arizona State University
Phoenix, Arizona
Diana Hagler, MSN-Ed, RN, CCRN
TeleHealth ICU RN, Adjunct Faculty
Banner Health, Grand Canyon University,
Maricopa Community Colleges
Phoenix, Arizona
Hope Hinchman, MSN, RN
Clinical Instructor
University of Nevada, Las Vegas
Las Vegas, Nevada
Sarah R. Jean Baptiste, MS-PA
Physician Assistant
Oregon Health Science University
Portland, Oregon
Michael Johnson, PhD, RN, PMH-BC, CNE
Director of Clinical Affairs and Associate Professor
School of Nursing
Nevada State College
Henderson, Nevada
Lisa M. Nicholas, MSN, RN
Lecturer, Clinical Instructor
University of Nevada, Las Vegas
Las Vegas, Nevada
Karen L. Petersen, MSN-L, RN, MNN
Nursing Faculty
Paradise Valley Community College
Phoenix, Arizona
Paula Richards, BA
Trauma Informed Care Interventionist
Dialectical Behavior Therapy Trained
Clinical Counselor
Baystate Medical Center
Springeld, Massachusetts
Kelly Rybacki, MSN, RN
Instructor of Nursing
Paradise Valley Community College
Phoenix, Arizona
Dieu-My Thi Tran, PhD, RN, CNE
Associate Professor of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Janelle Willis, MSN, APRN, CNE
Lecturer, Clinical Instructor
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Reviewers
Emily Brown, MSN, APRN, FNP-BC
Family Nurse Practitioner
University Medical Center
Las Vegas, Nevada
Alena Grewal, MSN, APRN, FNP-BC
Assistant Professor of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Jessica Grimm, DNP, APRN, ACNP-BC, CNE
Associate Professor of Nursing
Touro University Nevada
Henderson, Nevada;
Assistant Professor of Anesthesia and Perioperative Medicine
Oregon Health State University
Portland, Oregon
James Guilbault, PharmD, BS, RPh
Pharmacy Manager and Clinical Staff Pharmacist
Walgreens Pharmacy, Mercy Medical Center,
MCPHS University
Springeld, Massachusetts
Debra Hagler, PhD, RN, aCNS-BC, cNE, CHSE, ANEF,
FAAN
Clinical Professor
Edson College of Nursing and Health Innovation
Arizona State University
Phoenix, Arizona
Diana Hagler, MSN-Ed, RN, CCRN
TeleHealth ICU RN, Adjunct Faculty
Banner Health, Grand Canyon University,
Maricopa Community Colleges
Phoenix, Arizona
Hope Hinchman, MSN, RN
Clinical Instructor
University of Nevada, Las Vegas
Las Vegas, Nevada
Sarah R. Jean Baptiste, MS-PA
Physician Assistant
Oregon Health Science University
Portland, Oregon
Michael Johnson, PhD, RN, PMH-BC, CNE
Director of Clinical Affairs and Associate Professor
School of Nursing
Nevada State College
Henderson, Nevada
Lisa M. Nicholas, MSN, RN
Lecturer, Clinical Instructor
University of Nevada, Las Vegas
Las Vegas, Nevada
Karen L. Petersen, MSN-L, RN, MNN
Nursing Faculty
Paradise Valley Community College
Phoenix, Arizona
Paula Richards, BA
Trauma Informed Care Interventionist
Dialectical Behavior Therapy Trained
Clinical Counselor
Baystate Medical Center
Springeld, Massachusetts
Kelly Rybacki, MSN, RN
Instructor of Nursing
Paradise Valley Community College
Phoenix, Arizona
Dieu-My Thi Tran, PhD, RN, CNE
Associate Professor of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Janelle Willis, MSN, APRN, CNE
Lecturer, Clinical Instructor
School of Nursing
University of Nevada, Las Vegas
Las Vegas, Nevada
Reviewers
Loading page 13...
xi
Linda Anne Silvestri, PhD, RN
“To laugh often and much, to appreciate beauty, to nd the
best in others, to leave the world a bit better, to know that
even one life has breathed easier because you have lived, this
is to have succeeded.”
—Ralph Waldo Emerson
Angela Elizabeth Silvestri, PhD, APRN,
FNP-BC, CNE
“The climb to the top is arduous and steep. People become
exhausted, frustrated, and disenchanted, and are often
tempted to give up. Genuine acts of caring draw people for-
ward.”
-James M. Kouzes
Welcome to Saunders Pyramid to
Success!
An Essential Resource for Test Success
Saunders Comprehensive Review for the NCLEX-RN® Exami-
nation is one in a series of products designed to assist you
in achieving your goal of becoming a registered nurse.
This text will provide you with a comprehensive review
of all nursing content areas specically related to the cur-
rent test plan for the Next Generation NCLEX-RN exami-
nation, which is implemented by the National Council
of State Boards of Nursing. This resource will help you
achieve success on your nursing examinations during
nursing school and on the NCLEX-RN examination.
Organization
This book contains 19 units and 70 chapters. The chap-
ters are designed to identify specic components of
nursing content. They contain practice questions, both
multiple-choice and alternate item formats, that reect
the chapter content and the current test plan for the
NCLEX-RN examination. All questions in the book and
on the Evolve site are presented in NCLEX-style format.
The NCLEX test plan identies a framework based
on Client Needs. These Client Needs categories include
Safe and Effective Care Environment, Health Promotion
and Maintenance, Psychosocial Integrity, and Physi-
ological Integrity. Integrated Processes are also identied
as a component of the test plan. These include Caring,
Communication and Documentation, Culture and
Spirituality, Nursing Process, and Teaching and Learn-
ing. All chapters address the components of the test
plan framework.
Special Features of the Book
Pyramid Terms
Pyramid Terms are important to the discussion of the
content in the chapters in each unit. Therefore, they are
in bold green type throughout the content section of
each chapter. Denitions can be reviewed in the Audio
Glossary on the Evolve site.
Pyramid to Success
The Pyramid to Success, a featured part of each unit intro-
duction, provides you with an overview, guidance, and
direction regarding the focus of review in the particular
content area, as well as the content area’s relative impor-
tance to the test plan for the NCLEX-RN examination.
The Pyramid to Success reviews the Client Needs and pro-
vides learning outcomes as they pertain to the content
in that unit. These learning outcomes identify the spe-
cic components and cognitive skills to keep in mind as
you review each chapter.
Priority Concepts
Each chapter identies two Priority Concepts reective
of its content. These Priority Concepts will assist you to
focus on the important aspects of the content and asso-
ciated nursing interventions. These Priority Concepts
are also helpful for those students who are learning in a
concept-based curriculum.
Pyramid Points
Pyramid Points ( ) are placed next to specic content
throughout the chapters. The Pyramid Points highlight
content that is important for preparing for the NCLEX-
RN examination and identify content that is likely to
appear on the NCLEX-RN examination.
Preface
Linda Anne Silvestri, PhD, RN
“To laugh often and much, to appreciate beauty, to nd the
best in others, to leave the world a bit better, to know that
even one life has breathed easier because you have lived, this
is to have succeeded.”
—Ralph Waldo Emerson
Angela Elizabeth Silvestri, PhD, APRN,
FNP-BC, CNE
“The climb to the top is arduous and steep. People become
exhausted, frustrated, and disenchanted, and are often
tempted to give up. Genuine acts of caring draw people for-
ward.”
-James M. Kouzes
Welcome to Saunders Pyramid to
Success!
An Essential Resource for Test Success
Saunders Comprehensive Review for the NCLEX-RN® Exami-
nation is one in a series of products designed to assist you
in achieving your goal of becoming a registered nurse.
This text will provide you with a comprehensive review
of all nursing content areas specically related to the cur-
rent test plan for the Next Generation NCLEX-RN exami-
nation, which is implemented by the National Council
of State Boards of Nursing. This resource will help you
achieve success on your nursing examinations during
nursing school and on the NCLEX-RN examination.
Organization
This book contains 19 units and 70 chapters. The chap-
ters are designed to identify specic components of
nursing content. They contain practice questions, both
multiple-choice and alternate item formats, that reect
the chapter content and the current test plan for the
NCLEX-RN examination. All questions in the book and
on the Evolve site are presented in NCLEX-style format.
The NCLEX test plan identies a framework based
on Client Needs. These Client Needs categories include
Safe and Effective Care Environment, Health Promotion
and Maintenance, Psychosocial Integrity, and Physi-
ological Integrity. Integrated Processes are also identied
as a component of the test plan. These include Caring,
Communication and Documentation, Culture and
Spirituality, Nursing Process, and Teaching and Learn-
ing. All chapters address the components of the test
plan framework.
Special Features of the Book
Pyramid Terms
Pyramid Terms are important to the discussion of the
content in the chapters in each unit. Therefore, they are
in bold green type throughout the content section of
each chapter. Denitions can be reviewed in the Audio
Glossary on the Evolve site.
Pyramid to Success
The Pyramid to Success, a featured part of each unit intro-
duction, provides you with an overview, guidance, and
direction regarding the focus of review in the particular
content area, as well as the content area’s relative impor-
tance to the test plan for the NCLEX-RN examination.
The Pyramid to Success reviews the Client Needs and pro-
vides learning outcomes as they pertain to the content
in that unit. These learning outcomes identify the spe-
cic components and cognitive skills to keep in mind as
you review each chapter.
Priority Concepts
Each chapter identies two Priority Concepts reective
of its content. These Priority Concepts will assist you to
focus on the important aspects of the content and asso-
ciated nursing interventions. These Priority Concepts
are also helpful for those students who are learning in a
concept-based curriculum.
Pyramid Points
Pyramid Points ( ) are placed next to specic content
throughout the chapters. The Pyramid Points highlight
content that is important for preparing for the NCLEX-
RN examination and identify content that is likely to
appear on the NCLEX-RN examination.
Preface
Loading page 14...
Prefacexii
Pyramid Alerts
Pyramid Alerts are the red text found throughout the
chapters that alert you to important information about
nursing concepts. These alerts identify concepts that are
important to remember and relate to content that typi-
cally appears on the NCLEX-RN examination.
Clinical Judgment Boxes
Clinical Judgment (CJ) Boxes are located in every chap-
ter in the book. These boxes present a clinical scenario
that relates to one of the six cognitive skills (recognize
cues, analyze cues, prioritize hypotheses, generate solutions,
take action, evaluate outcomes) that will be measured in
the Next Generation NCLEX (NGN) exam. These CJ
boxes provide the thinking process needed and neces-
sary information to make a clinical decision.
Special Features Found on Evolve
Pretest and Study Calendar
The accompanying Evolve site contains a 75-question
pretest and a 75-question posttest that provide you
with feedback on your strengths and areas in need of
improvement. The results of your pretest will generate
an individualized study calendar to guide you in your
preparation for the NCLEX examination. Once you
have completed your review of the practice questions
in this resource, you can take the posttest to evaluate
your improvement and need for any additional review
in preparation for the NCLEX. After completion of each
test you are provided with the opportunity to review
the answers, rationales, and strategies, and we highly
encourage you to do this.
Audio Questions
The accompanying Evolve site contains Audio Questions
representative of content addressed in the current test
plan for the NCLEX-RN examination. These questions
are in NCLEX-style format, and each question presents
an audio sound, such as lung sounds, as a component
of the question.
Next Generation NCLEX ® (NGN) Case Studies and
NGN Test Questions
The accompanying Evolve site contains stand-alone
items and unfolding case studies. The clinical judgment
stand-alone items provide a clinical scenario and are
accompanied by one NGN test question in either a Bow-
tie or a Trend item format. These stand-alone items can
measure up to all of the cognitive skills of the NCSBN
Clinical Judgment Measurement Model (NCJMM).
These cognitive skills include Recognize Cues, Analyze
Cues, Prioritize Hypotheses, Generate Solutions, Take
Action, and Evaluate Outcomes. Each unfolding case
study is accompanied by six NGN test items, each mea-
suring one of the cognitive skills in sequential order.
Audio Review Summaries
The companion Evolve site includes three Audio Review
Summaries that cover challenging subject areas addressed
in the test plan for the NCLEX-RN examination, including
Pharmacology, Acid-Base Balance, and Fluids and Electrolytes.
Practice Questions
While preparing for the NCLEX-RN examination, it is
crucial for students to practice answering test questions.
This book contains multiple-choice and alternate item
format questions. The accompanying software includes
all the questions from the book, plus additional new
Evolve questions for a total of more than 5700 ques-
tions. The alternate item format questions in the book
and on the accompanying Evolve site may be presented
as one of the following:
◼ Fill-in-the-blank question
◼ Multiple-response question
◼ Prioritizing (ordered response) question
◼ Figure/illustration question
◼ Graphic options question, in which each option con-
tains a gure or illustration
◼ Chart/exhibit question
◼ Audio question
◼ NGN stand-alone items and unfolding case studies
The NGN stand-alone items and unfolding case studies
provide you with practice in prioritizing, decision-
making, and critical thinking, and strengthen your
clinical judgment skills.
Multiple-Choice and Alternate Item Format Questions
Starting with Unit II, each chapter is followed by a
practice test. Each practice test contains several ques-
tions reective of the content in the chapter and those
presented on the NCLEX-RN examination. These ques-
tions provide you with practice in prioritizing, decision-
making, critical thinking, and clinical judgment skills.
Chapter 1 of this book provides a description of each
question type. The Next Generation NCLEX (NGN) is
also discussed in this chapter.
The answer section for each practice question through-
out the chapters and on the Evolve site provides the cor-
rect answer, the rationale for the correct and incorrect
options, and a test-taking strategy that will assist you in
answering the question correctly. The test-taking strategy
is highlighted in bold blue type. This highlighting will
provide you with guidance and direction for further reme-
diation in the Saunders Clinical Judgment and Test-Taking
Strategies: Passing Nursing School and the NCLEX® Exam.
The categories identied in each practice question on
the Evolve site include Level of Cognitive Ability, Client
Needs, Integrated Process, Clinical Judgment/Cognitive
Skill, the nursing Content Area, the Health Problem, and
Priority Concepts. Every question on the accompanying
Pyramid Alerts
Pyramid Alerts are the red text found throughout the
chapters that alert you to important information about
nursing concepts. These alerts identify concepts that are
important to remember and relate to content that typi-
cally appears on the NCLEX-RN examination.
Clinical Judgment Boxes
Clinical Judgment (CJ) Boxes are located in every chap-
ter in the book. These boxes present a clinical scenario
that relates to one of the six cognitive skills (recognize
cues, analyze cues, prioritize hypotheses, generate solutions,
take action, evaluate outcomes) that will be measured in
the Next Generation NCLEX (NGN) exam. These CJ
boxes provide the thinking process needed and neces-
sary information to make a clinical decision.
Special Features Found on Evolve
Pretest and Study Calendar
The accompanying Evolve site contains a 75-question
pretest and a 75-question posttest that provide you
with feedback on your strengths and areas in need of
improvement. The results of your pretest will generate
an individualized study calendar to guide you in your
preparation for the NCLEX examination. Once you
have completed your review of the practice questions
in this resource, you can take the posttest to evaluate
your improvement and need for any additional review
in preparation for the NCLEX. After completion of each
test you are provided with the opportunity to review
the answers, rationales, and strategies, and we highly
encourage you to do this.
Audio Questions
The accompanying Evolve site contains Audio Questions
representative of content addressed in the current test
plan for the NCLEX-RN examination. These questions
are in NCLEX-style format, and each question presents
an audio sound, such as lung sounds, as a component
of the question.
Next Generation NCLEX ® (NGN) Case Studies and
NGN Test Questions
The accompanying Evolve site contains stand-alone
items and unfolding case studies. The clinical judgment
stand-alone items provide a clinical scenario and are
accompanied by one NGN test question in either a Bow-
tie or a Trend item format. These stand-alone items can
measure up to all of the cognitive skills of the NCSBN
Clinical Judgment Measurement Model (NCJMM).
These cognitive skills include Recognize Cues, Analyze
Cues, Prioritize Hypotheses, Generate Solutions, Take
Action, and Evaluate Outcomes. Each unfolding case
study is accompanied by six NGN test items, each mea-
suring one of the cognitive skills in sequential order.
Audio Review Summaries
The companion Evolve site includes three Audio Review
Summaries that cover challenging subject areas addressed
in the test plan for the NCLEX-RN examination, including
Pharmacology, Acid-Base Balance, and Fluids and Electrolytes.
Practice Questions
While preparing for the NCLEX-RN examination, it is
crucial for students to practice answering test questions.
This book contains multiple-choice and alternate item
format questions. The accompanying software includes
all the questions from the book, plus additional new
Evolve questions for a total of more than 5700 ques-
tions. The alternate item format questions in the book
and on the accompanying Evolve site may be presented
as one of the following:
◼ Fill-in-the-blank question
◼ Multiple-response question
◼ Prioritizing (ordered response) question
◼ Figure/illustration question
◼ Graphic options question, in which each option con-
tains a gure or illustration
◼ Chart/exhibit question
◼ Audio question
◼ NGN stand-alone items and unfolding case studies
The NGN stand-alone items and unfolding case studies
provide you with practice in prioritizing, decision-
making, and critical thinking, and strengthen your
clinical judgment skills.
Multiple-Choice and Alternate Item Format Questions
Starting with Unit II, each chapter is followed by a
practice test. Each practice test contains several ques-
tions reective of the content in the chapter and those
presented on the NCLEX-RN examination. These ques-
tions provide you with practice in prioritizing, decision-
making, critical thinking, and clinical judgment skills.
Chapter 1 of this book provides a description of each
question type. The Next Generation NCLEX (NGN) is
also discussed in this chapter.
The answer section for each practice question through-
out the chapters and on the Evolve site provides the cor-
rect answer, the rationale for the correct and incorrect
options, and a test-taking strategy that will assist you in
answering the question correctly. The test-taking strategy
is highlighted in bold blue type. This highlighting will
provide you with guidance and direction for further reme-
diation in the Saunders Clinical Judgment and Test-Taking
Strategies: Passing Nursing School and the NCLEX® Exam.
The categories identied in each practice question on
the Evolve site include Level of Cognitive Ability, Client
Needs, Integrated Process, Clinical Judgment/Cognitive
Skill, the nursing Content Area, the Health Problem, and
Priority Concepts. Every question on the accompanying
Loading page 15...
Preface xiii
Evolve site is organized by these question codes, so you
can customize your study session to be as specic or as
generic as you need. Additionally, a link to view nor-
mal laboratory reference intervals is provided with each
practice question.
Pharmacology and Medication
Calculations Review
Students consistently state that pharmacology is an
area with which they need assistance. The NCLEX-RN
test plan continues to incorporate pharmacology in
the examination, but only the generic drug names will
be included. Therefore, pharmacology chapters have
been included for your review and practice. This book
includes 13 pharmacology chapters, a medication and
intravenous prescriptions calculation chapter, and a
pediatric medication administration and calculation
chapter. Each of these chapters is followed by a practice
test that uses the same question format described earlier.
This book contains numerous pharmacology questions.
Additionally, more than 1000 pharmacology questions
can be found on the accompanying Evolve site.
Next Generation NCLEX (NGN)
Questions
As described above, the accompanying Evolve site con-
tains stand-alone items and unfolding case studies. The
NCSBN has conducted rigorous research over the past
several years to develop NGN case studies and test items
that will effectively measure clinical judgment. The
NCSBN will launch the NGN questions on the exami-
nation starting in April 2023, and these item types are
designed to test the candidate’s ability to make safe and
competent clinical judgments. The information in this
book about the NGN reects the most up-to-date infor-
mation at the time of the printing of this book. Since
the NCSBN continues to research and collect data on
the NGN items, additional and continuous changes
could be made. We encourage you to access the NCSBN
website at www.ncsbn.org for these latest updates. The
Evolve site for this resource provides you with NGN
stand-alone items and unfolding case studies with
accompanying test items that are reective of the item
types that NCSBN has indicated (as of the time of this
publication) will be presented.
How to Use This Book
Saunders Comprehensive Review for the NCLEX-RN® Exam-
ination is especially designed to help you with your suc-
cessful journey to the peak of the Saunders Pyramid to
Success: becoming a registered nurse! As you begin your
journey through this book, you will be introduced to all
of the important points regarding the current NCLEX-
RN examination, the process of testing, and unique
and special tips regarding how to prepare yourself for
this very important examination. You will also be intro-
duced to the NGN and the types of case studies and test
items that will be on the NCLEX-RN.
You should begin your process through the Saun-
ders Pyramid to Success by reading all of Unit I in this
book and becoming familiar with the central points
regarding the NCLEX-RN examination, including the
NGN. Chapter 2 describes self-efcacy and the unique
and special tips regarding how to prepare yourself both
academically and nonacademically for this important
examination. Be sure to read Chapter 3, written by a
nursing graduate who recently passed the examination,
and note what the graduate has to say about the testing
experience. Chapter 4 will provide you with the critical
testing strategies that will guide you in selecting the cor-
rect option or assist you in selecting an answer to a ques-
tion if you must guess. Keep these strategies in mind as
you proceed through this book. Continue by studying
the specic content areas addressed in Units II through
XIX. Review the denitions of the Pyramid Terms, located
in each chapter, and the Pyramid to Success notes and the
Client Needs and Learning Outcomes, located in each
unit introduction. Read through the chapters and focus
on the Pyramid Points and Pyramid Alerts, which iden-
tify the areas most likely to be tested on the NCLEX-
RN examination. Pay particular attention to the Clinical
Judgment boxes because they provide information about
the cognitive skills in the NCSBN Clinical Judgment
Measurement Model and the thinking processes in mak-
ing an interpretation or decision.
As you read each chapter, identify your areas of
strength and those in need of further review. Highlight
these areas, and test your abilities by taking all prac-
tice tests provided at the end of the chapters. Be sure to
review all rationales and test-taking strategies.
After reviewing all chapters in the book, reect and
identify any areas requiring further review; then take
the time to review those areas in both the book and the
companion Evolve site. In preparation for the NCLEX-
RN examination, be sure to take the pretest on the
Evolve site and generate your study calendar. Follow the
calendar for your review because the calendar represents
your pretest results and the best study path to follow
based on your strong areas and content areas in need of
review. Also, be sure to access the NGN cases and items
and the Audio Review Summaries as part of your prepara-
tion for the NCLEX-RN examination.
Climbing the Pyramid to Success
The purpose of this book is to provide a comprehensive
review of the nursing content you will be tested on during
Evolve site is organized by these question codes, so you
can customize your study session to be as specic or as
generic as you need. Additionally, a link to view nor-
mal laboratory reference intervals is provided with each
practice question.
Pharmacology and Medication
Calculations Review
Students consistently state that pharmacology is an
area with which they need assistance. The NCLEX-RN
test plan continues to incorporate pharmacology in
the examination, but only the generic drug names will
be included. Therefore, pharmacology chapters have
been included for your review and practice. This book
includes 13 pharmacology chapters, a medication and
intravenous prescriptions calculation chapter, and a
pediatric medication administration and calculation
chapter. Each of these chapters is followed by a practice
test that uses the same question format described earlier.
This book contains numerous pharmacology questions.
Additionally, more than 1000 pharmacology questions
can be found on the accompanying Evolve site.
Next Generation NCLEX (NGN)
Questions
As described above, the accompanying Evolve site con-
tains stand-alone items and unfolding case studies. The
NCSBN has conducted rigorous research over the past
several years to develop NGN case studies and test items
that will effectively measure clinical judgment. The
NCSBN will launch the NGN questions on the exami-
nation starting in April 2023, and these item types are
designed to test the candidate’s ability to make safe and
competent clinical judgments. The information in this
book about the NGN reects the most up-to-date infor-
mation at the time of the printing of this book. Since
the NCSBN continues to research and collect data on
the NGN items, additional and continuous changes
could be made. We encourage you to access the NCSBN
website at www.ncsbn.org for these latest updates. The
Evolve site for this resource provides you with NGN
stand-alone items and unfolding case studies with
accompanying test items that are reective of the item
types that NCSBN has indicated (as of the time of this
publication) will be presented.
How to Use This Book
Saunders Comprehensive Review for the NCLEX-RN® Exam-
ination is especially designed to help you with your suc-
cessful journey to the peak of the Saunders Pyramid to
Success: becoming a registered nurse! As you begin your
journey through this book, you will be introduced to all
of the important points regarding the current NCLEX-
RN examination, the process of testing, and unique
and special tips regarding how to prepare yourself for
this very important examination. You will also be intro-
duced to the NGN and the types of case studies and test
items that will be on the NCLEX-RN.
You should begin your process through the Saun-
ders Pyramid to Success by reading all of Unit I in this
book and becoming familiar with the central points
regarding the NCLEX-RN examination, including the
NGN. Chapter 2 describes self-efcacy and the unique
and special tips regarding how to prepare yourself both
academically and nonacademically for this important
examination. Be sure to read Chapter 3, written by a
nursing graduate who recently passed the examination,
and note what the graduate has to say about the testing
experience. Chapter 4 will provide you with the critical
testing strategies that will guide you in selecting the cor-
rect option or assist you in selecting an answer to a ques-
tion if you must guess. Keep these strategies in mind as
you proceed through this book. Continue by studying
the specic content areas addressed in Units II through
XIX. Review the denitions of the Pyramid Terms, located
in each chapter, and the Pyramid to Success notes and the
Client Needs and Learning Outcomes, located in each
unit introduction. Read through the chapters and focus
on the Pyramid Points and Pyramid Alerts, which iden-
tify the areas most likely to be tested on the NCLEX-
RN examination. Pay particular attention to the Clinical
Judgment boxes because they provide information about
the cognitive skills in the NCSBN Clinical Judgment
Measurement Model and the thinking processes in mak-
ing an interpretation or decision.
As you read each chapter, identify your areas of
strength and those in need of further review. Highlight
these areas, and test your abilities by taking all prac-
tice tests provided at the end of the chapters. Be sure to
review all rationales and test-taking strategies.
After reviewing all chapters in the book, reect and
identify any areas requiring further review; then take
the time to review those areas in both the book and the
companion Evolve site. In preparation for the NCLEX-
RN examination, be sure to take the pretest on the
Evolve site and generate your study calendar. Follow the
calendar for your review because the calendar represents
your pretest results and the best study path to follow
based on your strong areas and content areas in need of
review. Also, be sure to access the NGN cases and items
and the Audio Review Summaries as part of your prepara-
tion for the NCLEX-RN examination.
Climbing the Pyramid to Success
The purpose of this book is to provide a comprehensive
review of the nursing content you will be tested on during
Loading page 16...
Prefacexiv
the NCLEX-RN examination. However, Saunders Compre-
hensive Review for the NCLEX-RN® Examination is intended
to do more than simply prepare you for the rigors of the
NCLEX-RN examination; this book is also meant to serve
as a valuable study tool that you can refer to throughout
your nursing program, with specic customizable Evolve
site selections, including a selection for NGN cases and
test items, to help identify and reinforce key content areas
and prepare you for your nursing exams.
After using this book for comprehensive content
review, your next step in the Pyramid to Success is to get
additional practice with the Q&A review product. Saun-
ders Q&A Review for the NCLEX-RN® Examination offers
more than 6000 unique practice questions in the book
and on the companion Evolve site. The questions are
focused on the Client Needs and Integrated Processes
of the NCLEX-RN test plan, making it easy to access
your study area of choice. The Evolve site for this book
also provides you with NGN cases and test items. For
on-the-go Q&A review, you can pick up Saunders Q&A
Review Cards for the NCLEX-RN® Examination.
Your nal step on the Pyramid to Success is to mas-
ter the online review. The HESI/Saunders Online Review
for the NCLEX-RN® Examination provides an interactive
and individualized platform to get you ready for your
NCLEX exam. This online course provides 10 high-level
content modules, supplemented with instructional vid-
eos, animations, audio, illustrations, case studies, and
several subject matter exams. End-of-module practice
tests are provided, along with several Crossing the Finish
Line practice tests. In addition, you can assess your prog-
ress with a Pretest, Test Yourself quizzes, and a Comprehen-
sive Exam in a computerized environment that prepares
you for the actual NCLEX-RN examination. NGN cases
and test items are also provided.
At the base of the Pyramid to Success are our test-
taking strategies, which provide a foundation for under-
standing and unpacking the complexities of NCLEX-RN
examination questions, including alternate item formats,
NGN stand-alone items, and unfolding case studies with
accompanying NGN items. Saunders Clinical Judgment
and Test-Taking Strategies: Passing Nursing School and the
NCLEX® Exam takes a detailed look at clinical judgment
and all of the test-taking strategies you will need to know
in order to pass any nursing examination, including the
Next Generation NCLEX-RN. Special tips are integrated
for nursing students, and more than 1200 practice ques-
tions are included so that you can apply the testing strate-
gies. NGN questions are included on the Evolve site.
Good luck with your journey through the Saun-
ders Pyramid to Success. We wish you continued success
throughout your new career as a registered nurse!
the NCLEX-RN examination. However, Saunders Compre-
hensive Review for the NCLEX-RN® Examination is intended
to do more than simply prepare you for the rigors of the
NCLEX-RN examination; this book is also meant to serve
as a valuable study tool that you can refer to throughout
your nursing program, with specic customizable Evolve
site selections, including a selection for NGN cases and
test items, to help identify and reinforce key content areas
and prepare you for your nursing exams.
After using this book for comprehensive content
review, your next step in the Pyramid to Success is to get
additional practice with the Q&A review product. Saun-
ders Q&A Review for the NCLEX-RN® Examination offers
more than 6000 unique practice questions in the book
and on the companion Evolve site. The questions are
focused on the Client Needs and Integrated Processes
of the NCLEX-RN test plan, making it easy to access
your study area of choice. The Evolve site for this book
also provides you with NGN cases and test items. For
on-the-go Q&A review, you can pick up Saunders Q&A
Review Cards for the NCLEX-RN® Examination.
Your nal step on the Pyramid to Success is to mas-
ter the online review. The HESI/Saunders Online Review
for the NCLEX-RN® Examination provides an interactive
and individualized platform to get you ready for your
NCLEX exam. This online course provides 10 high-level
content modules, supplemented with instructional vid-
eos, animations, audio, illustrations, case studies, and
several subject matter exams. End-of-module practice
tests are provided, along with several Crossing the Finish
Line practice tests. In addition, you can assess your prog-
ress with a Pretest, Test Yourself quizzes, and a Comprehen-
sive Exam in a computerized environment that prepares
you for the actual NCLEX-RN examination. NGN cases
and test items are also provided.
At the base of the Pyramid to Success are our test-
taking strategies, which provide a foundation for under-
standing and unpacking the complexities of NCLEX-RN
examination questions, including alternate item formats,
NGN stand-alone items, and unfolding case studies with
accompanying NGN items. Saunders Clinical Judgment
and Test-Taking Strategies: Passing Nursing School and the
NCLEX® Exam takes a detailed look at clinical judgment
and all of the test-taking strategies you will need to know
in order to pass any nursing examination, including the
Next Generation NCLEX-RN. Special tips are integrated
for nursing students, and more than 1200 practice ques-
tions are included so that you can apply the testing strate-
gies. NGN questions are included on the Evolve site.
Good luck with your journey through the Saun-
ders Pyramid to Success. We wish you continued success
throughout your new career as a registered nurse!
Loading page 17...
xv
A Few Words From Linda
There are many individuals who in their own ways have
contributed to my success in making my professional
dreams become a reality. My sincere appreciation and
warmest thanks are extended to all of them.
First, I want to acknowledge my parents, who opened
my door of opportunity in education. I thank my
mother, Frances Mary, for all of her love, support, and
assistance as I continuously worked to achieve my pro-
fessional goals. I thank my father, Arnold Lawrence, who
always provided insightful words of encouragement. My
memories of their love and support will always remain
in my heart. I am certain that they are very proud of my
professional accomplishments.
I also thank my best friend and love of my life, my
husband, Larry; my sister, Dianne Elodia, and her hus-
band, Lawrence; my brother, Lawrence Peter, and my
sister-in-law, Mary Elizabeth; my cousin Paula; and my
nieces and nephews, Angela, Katie, Gina, Karen, Bri-
anna, Gabby, and Nicholas, who were continuously
supportive, giving, and helpful during my research and
preparation of this publication. They were always there
and by my side whenever I needed them.
I want to thank my nursing students at the Com-
munity College of Rhode Island who approached me
in 1991 and persuaded me to assist them in preparing
to take the NCLEX-RN examination. Their enthusi-
asm and inspiration led to the commencement of my
professional endeavors in conducting review courses
for the NCLEX-RN examination for nursing students.
I also thank the numerous nursing students who have
attended my review courses for their willingness to
share their needs and ideas. Their input has certainly
added a special uniqueness to all of the publications in
the Pyramid to Success.
I also wish to acknowledge all of the nursing faculty
who taught in my review courses for the NCLEX-RN exam-
ination. Their commitment, dedication, and expertise have
certainly assisted nursing students in achieving success
with the NCLEX-RN examination. I also want to extend a
very special thank-you to my niece, Angela, for joining me
in preparing and authoring these NCLEX resources. Angela
is wonderful to work with. Her tremendous theoretical and
clinical knowledge and expertise and her consistently out-
standing ideas and work in creating clinical judgment test-
taking strategies certainly added to the excellent quality of
this product and all of the other products in the Pyramid to
Success. She is very dedicated to promoting and ensuring
student success. Thank you, Angela!
A special thank-you goes to Loren Wilson, former
Senior Vice President, for her years of expert guidance
and continuous support for all of the products in the
Pyramid to Success.
I would also like to acknowledge Patricia Mieg and
Jeff Price, former educational sales representatives, who
encouraged me to submit my ideas and initial work
for the rst edition of this book to the W.B. Saunders
Company.
And nally, a very sincere and special acknowledg-
ment to my husband, Laurent (Larry) W. Valliere, for
his contribution to this publication, for teaching in my
review courses for the NCLEX-RN examination, and for
his commitment and dedication in assisting my nursing
students to prepare for the examination from a nonaca-
demic point of view. I thank him for all of his continu-
ous support; he was so loyal and loving to me each and
every moment as I worked to achieve my professional
goals. Larry, you are my “rock of support!” Thank you
so much!
A Few Words From Angela
There are many people who contributed to my success
in my work on this product. I am very grateful for their
continued support in all of my endeavors.
First and foremost, I would like to thank my hus-
band, Brent, for his lighthearted and positive attitude.
He always knows how to make me laugh, especially
when I’m stressed. All of this would not be possible
without him!
I would also like to thank my parents, Mary and
Larry, for their continued support throughout the years.
Their words of encouragement and wisdom have been
tremendously important to my success. I also don’t
Acknowledgments
A Few Words From Linda
There are many individuals who in their own ways have
contributed to my success in making my professional
dreams become a reality. My sincere appreciation and
warmest thanks are extended to all of them.
First, I want to acknowledge my parents, who opened
my door of opportunity in education. I thank my
mother, Frances Mary, for all of her love, support, and
assistance as I continuously worked to achieve my pro-
fessional goals. I thank my father, Arnold Lawrence, who
always provided insightful words of encouragement. My
memories of their love and support will always remain
in my heart. I am certain that they are very proud of my
professional accomplishments.
I also thank my best friend and love of my life, my
husband, Larry; my sister, Dianne Elodia, and her hus-
band, Lawrence; my brother, Lawrence Peter, and my
sister-in-law, Mary Elizabeth; my cousin Paula; and my
nieces and nephews, Angela, Katie, Gina, Karen, Bri-
anna, Gabby, and Nicholas, who were continuously
supportive, giving, and helpful during my research and
preparation of this publication. They were always there
and by my side whenever I needed them.
I want to thank my nursing students at the Com-
munity College of Rhode Island who approached me
in 1991 and persuaded me to assist them in preparing
to take the NCLEX-RN examination. Their enthusi-
asm and inspiration led to the commencement of my
professional endeavors in conducting review courses
for the NCLEX-RN examination for nursing students.
I also thank the numerous nursing students who have
attended my review courses for their willingness to
share their needs and ideas. Their input has certainly
added a special uniqueness to all of the publications in
the Pyramid to Success.
I also wish to acknowledge all of the nursing faculty
who taught in my review courses for the NCLEX-RN exam-
ination. Their commitment, dedication, and expertise have
certainly assisted nursing students in achieving success
with the NCLEX-RN examination. I also want to extend a
very special thank-you to my niece, Angela, for joining me
in preparing and authoring these NCLEX resources. Angela
is wonderful to work with. Her tremendous theoretical and
clinical knowledge and expertise and her consistently out-
standing ideas and work in creating clinical judgment test-
taking strategies certainly added to the excellent quality of
this product and all of the other products in the Pyramid to
Success. She is very dedicated to promoting and ensuring
student success. Thank you, Angela!
A special thank-you goes to Loren Wilson, former
Senior Vice President, for her years of expert guidance
and continuous support for all of the products in the
Pyramid to Success.
I would also like to acknowledge Patricia Mieg and
Jeff Price, former educational sales representatives, who
encouraged me to submit my ideas and initial work
for the rst edition of this book to the W.B. Saunders
Company.
And nally, a very sincere and special acknowledg-
ment to my husband, Laurent (Larry) W. Valliere, for
his contribution to this publication, for teaching in my
review courses for the NCLEX-RN examination, and for
his commitment and dedication in assisting my nursing
students to prepare for the examination from a nonaca-
demic point of view. I thank him for all of his continu-
ous support; he was so loyal and loving to me each and
every moment as I worked to achieve my professional
goals. Larry, you are my “rock of support!” Thank you
so much!
A Few Words From Angela
There are many people who contributed to my success
in my work on this product. I am very grateful for their
continued support in all of my endeavors.
First and foremost, I would like to thank my hus-
band, Brent, for his lighthearted and positive attitude.
He always knows how to make me laugh, especially
when I’m stressed. All of this would not be possible
without him!
I would also like to thank my parents, Mary and
Larry, for their continued support throughout the years.
Their words of encouragement and wisdom have been
tremendously important to my success. I also don’t
Acknowledgments
Loading page 18...
Acknowledgmentsxvi
know what I would do without their support in caring
for my kids!
I would like to thank my sister Katie, who is a won-
derful nurse. Her ambitions as a nursing student were so
inspiring and reminded me about why I’m so passion-
ate about being an educator. Thank you to my brother,
Nick, who always is positive and encouraging about my
work. His wit and sarcasm are always a great way to lift
your mood at the end of the day.
Finally, I want to extend a special thank you to Linda
for her collaboration, guidance, and expertise. Without
her, I would not be where I am today. Thank you, Linda!
A Few Words From Both Linda and Angela
First and foremost, we want to thank our associate edi-
tor, Jessica Grimm, for all of her dedicated and hard
work in editing and preparing manuscript for this edi-
tion. Her expertise and close attention to details have
certainly added to the quality of this resource.
We also want to acknowledge and thank Laurent W.
Valliere for writing a chapter addressing those important
self-efcacy and nonacademic test-preparation issues.
A very special thank-you goes to all of the review-
ers, contributors, and item writers who updated and
provided many of the practice questions, and to all of
the previous contributors to this book. You were all
awesome!
Additionally, we want to thank Paula Richards for
her expertise and input in reviewing our chapter titled
Population Health Nursing. Thank you, Paula!
We thank Dianne E. Fiorentino for her continuous
support and dedication to our work and in her research
and reference support and other administrative assistant
responsibilities for the ninth edition of this book. We
thank Karen Machnacz for her help with reference sup-
port, Jimmy Guilbault for providing medication research
support, and Mary and Larry Silvestri for their assistance
with getting through all of the tasks and projects we
needed completed. A special thank-you to all of you!
We also want to thank Donna Ignatavicius who cre-
ated the unfolding case studies for the Evolve site for
this book. She has been passionate about creating teach-
ing and learning strategies that promote thinking and
clinical judgment in nursing students. Her case studies
present real-world situations that nursing graduates are
likely to encounter in the clinical settings. Thank you
Donna!
We sincerely acknowledge and thank some very
important and special people from Elsevier. We thank
Heather Bays-Petrovic, Content Strategist, for her con-
tinuous support, enthusiasm, and expert professional
guidance throughout the preparation of this edition.
Heather, thank you so much—you are awesome! We
also thank Laurie Gower, Director of Development, for
always supporting our ideas and projects. Thank you,
Laurie! A very special thank-you goes to Laura Goodrich,
Senior Content Development Specialist, for her tremen-
dous amount of support and assistance, for prioritizing
for us to keep us on track, for her ideas for the product,
and for her professional and expert skills in organizing
and maintaining an enormous amount of manuscript
for production. And we thank Senior Content Develop-
ment Specialist Rebecca Leenhouts for her expertise in
assisting us to complete this book. Thank you, Becky!
We could not have completed this project without Laura
or Becky!
We want to acknowledge all of the staff at Elsevier
for their tremendous help throughout the preparation
and production of this publication. A special thanks
to all of them. We want to thank and acknowledge
Tamara Myers, Director, Traditional Nursing Program,
for reviewing our Population Health Nursing chap-
ter. Thank you Tamara! We thank Julie Eddy, Publish-
ing Services Manager, and Margaret Reid, Senior Book
Designer. You have all played such signicant roles in
nalizing this publication. And we need to especially
acknowledge Cindy Thoms, Senior Project Manager,
who so expertly managed all of our copyedited manu-
script and pages for review for this book. Cindy, you
were so organized, supportive, and so awesome to work
with. Your attention to the many details to ensure and
maintain the quality of this book was so greatly appreci-
ated. We thank you so much!
Lastly, a very special thank-you to all our nursing
students: past, present, and future. All of you light up
our lives! Your love and dedication to the profession of
nursing and your commitment to provide expert and
quality health care will bring never-ending rewards!
know what I would do without their support in caring
for my kids!
I would like to thank my sister Katie, who is a won-
derful nurse. Her ambitions as a nursing student were so
inspiring and reminded me about why I’m so passion-
ate about being an educator. Thank you to my brother,
Nick, who always is positive and encouraging about my
work. His wit and sarcasm are always a great way to lift
your mood at the end of the day.
Finally, I want to extend a special thank you to Linda
for her collaboration, guidance, and expertise. Without
her, I would not be where I am today. Thank you, Linda!
A Few Words From Both Linda and Angela
First and foremost, we want to thank our associate edi-
tor, Jessica Grimm, for all of her dedicated and hard
work in editing and preparing manuscript for this edi-
tion. Her expertise and close attention to details have
certainly added to the quality of this resource.
We also want to acknowledge and thank Laurent W.
Valliere for writing a chapter addressing those important
self-efcacy and nonacademic test-preparation issues.
A very special thank-you goes to all of the review-
ers, contributors, and item writers who updated and
provided many of the practice questions, and to all of
the previous contributors to this book. You were all
awesome!
Additionally, we want to thank Paula Richards for
her expertise and input in reviewing our chapter titled
Population Health Nursing. Thank you, Paula!
We thank Dianne E. Fiorentino for her continuous
support and dedication to our work and in her research
and reference support and other administrative assistant
responsibilities for the ninth edition of this book. We
thank Karen Machnacz for her help with reference sup-
port, Jimmy Guilbault for providing medication research
support, and Mary and Larry Silvestri for their assistance
with getting through all of the tasks and projects we
needed completed. A special thank-you to all of you!
We also want to thank Donna Ignatavicius who cre-
ated the unfolding case studies for the Evolve site for
this book. She has been passionate about creating teach-
ing and learning strategies that promote thinking and
clinical judgment in nursing students. Her case studies
present real-world situations that nursing graduates are
likely to encounter in the clinical settings. Thank you
Donna!
We sincerely acknowledge and thank some very
important and special people from Elsevier. We thank
Heather Bays-Petrovic, Content Strategist, for her con-
tinuous support, enthusiasm, and expert professional
guidance throughout the preparation of this edition.
Heather, thank you so much—you are awesome! We
also thank Laurie Gower, Director of Development, for
always supporting our ideas and projects. Thank you,
Laurie! A very special thank-you goes to Laura Goodrich,
Senior Content Development Specialist, for her tremen-
dous amount of support and assistance, for prioritizing
for us to keep us on track, for her ideas for the product,
and for her professional and expert skills in organizing
and maintaining an enormous amount of manuscript
for production. And we thank Senior Content Develop-
ment Specialist Rebecca Leenhouts for her expertise in
assisting us to complete this book. Thank you, Becky!
We could not have completed this project without Laura
or Becky!
We want to acknowledge all of the staff at Elsevier
for their tremendous help throughout the preparation
and production of this publication. A special thanks
to all of them. We want to thank and acknowledge
Tamara Myers, Director, Traditional Nursing Program,
for reviewing our Population Health Nursing chap-
ter. Thank you Tamara! We thank Julie Eddy, Publish-
ing Services Manager, and Margaret Reid, Senior Book
Designer. You have all played such signicant roles in
nalizing this publication. And we need to especially
acknowledge Cindy Thoms, Senior Project Manager,
who so expertly managed all of our copyedited manu-
script and pages for review for this book. Cindy, you
were so organized, supportive, and so awesome to work
with. Your attention to the many details to ensure and
maintain the quality of this book was so greatly appreci-
ated. We thank you so much!
Lastly, a very special thank-you to all our nursing
students: past, present, and future. All of you light up
our lives! Your love and dedication to the profession of
nursing and your commitment to provide expert and
quality health care will bring never-ending rewards!
Loading page 19...
Preparation
UNIT I
NCLEX-RN® Exam Preparation
UNIT I
NCLEX-RN® Exam Preparation
Loading page 20...
Preparation
The Pyramid to Success
Saunders Comprehensive Review for the NCLEX-RN ®
Examination
About This Resource and the NCLEX-RN ®
Examination
Welcome to the Pyramid to Success and Saunders Com-
prehensive Review for the NCLEX-RN® Examination. This
resource 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 unique and special tips regarding how to prepare
yourself for this important examination, both academi-
cally and nonacademically. You will read what a nursing
graduate who recently passed the NCLEX-RN exami-
nation 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 making an
educated guess if you are not entirely sure about the cor-
rect answer; they will also guide you in ways to answer
the NGN test items. Each unit in this book begins with
the Pyramid to Success. The Pyramid to Success addresses
specic points related to the NCLEX-RN examination.
Client Needs and activities as identied in the test plan
framework for the examination are listed, as are learn-
ing outcomes and competencies for the unit. Cognitive
Skills identied in the National Council of State Boards
of Nursing (NCSBN) Clinical Judgment Measurement
Model (NCJMM) are a focus in chapters and practice
questions. Pyramid Terms are key words that are dened
in the glossary on the accompanying Evolve site and set
in a green color throughout each chapter to direct your
attention to signicant points for the examination.
This resource provides you with nursing content
review, including the content identied in the current
NCLEX test plan, and practice questions of all types,
each chapter, you will nd Pyramid Point bullets
NCLEX-RN examination and Pyramid Alert bullets
in red text throughout the chapter that alert you to
important information about nursing concepts. Each
chapter includes Clinical Judgment: Cognitive Skill client
scenarios that focus on one of the cognitive skills.
The book contains 854 NCLEX-style questions. The
Evolve site accompanying this book contains all of the
questions from the book plus additional Evolve ques-
tions for a total of more than 6,000 practice questions.
The types of practice questions include multiple choice;
ll-in-the-blank; multiple-response (select all that
apply); ordered-response; questions that contain a g-
ure, chart/exhibit, or a graphic option item; and audio
item formats. Examples of some question types can be
located throughout this chapter. In addition, the NGN
item types are provided on the accompanying Evolve
site.
As you read each chapter, identify your strengths and
areas that are in need of further review.
Test your strengths and abilities by answering all
practice questions provided in this book and on the
accompanying Evolve site. Be sure to read all rationales
and test-taking strategies. The rationale provides you
with signicant information regarding the correct and
incorrect options. The test-taking strategy provides you
with the logical path to selecting the correct option. A
reference source and page number are provided so that
you can easily nd information you need to review in
another Elsevier text. Each practice question on the
accompanying Evolve site is coded on the basis of the
Clinical Judgment and the Next Generation
NCLEX (NGN)-RN ® Examination
Linda A. Silvestri, PhD, RN, FAAN
Angela E. Silvestri, PhD, APRN, FNP-BC, CNE
C H A P T E R 1
The Pyramid to Success
Saunders Comprehensive Review for the NCLEX-RN ®
Examination
About This Resource and the NCLEX-RN ®
Examination
Welcome to the Pyramid to Success and Saunders Com-
prehensive Review for the NCLEX-RN® Examination. This
resource 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 unique and special tips regarding how to prepare
yourself for this important examination, both academi-
cally and nonacademically. You will read what a nursing
graduate who recently passed the NCLEX-RN exami-
nation 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 making an
educated guess if you are not entirely sure about the cor-
rect answer; they will also guide you in ways to answer
the NGN test items. Each unit in this book begins with
the Pyramid to Success. The Pyramid to Success addresses
specic points related to the NCLEX-RN examination.
Client Needs and activities as identied in the test plan
framework for the examination are listed, as are learn-
ing outcomes and competencies for the unit. Cognitive
Skills identied in the National Council of State Boards
of Nursing (NCSBN) Clinical Judgment Measurement
Model (NCJMM) are a focus in chapters and practice
questions. Pyramid Terms are key words that are dened
in the glossary on the accompanying Evolve site and set
in a green color throughout each chapter to direct your
attention to signicant points for the examination.
This resource provides you with nursing content
review, including the content identied in the current
NCLEX test plan, and practice questions of all types,
each chapter, you will nd Pyramid Point bullets
NCLEX-RN examination and Pyramid Alert bullets
in red text throughout the chapter that alert you to
important information about nursing concepts. Each
chapter includes Clinical Judgment: Cognitive Skill client
scenarios that focus on one of the cognitive skills.
The book contains 854 NCLEX-style questions. The
Evolve site accompanying this book contains all of the
questions from the book plus additional Evolve ques-
tions for a total of more than 6,000 practice questions.
The types of practice questions include multiple choice;
ll-in-the-blank; multiple-response (select all that
apply); ordered-response; questions that contain a g-
ure, chart/exhibit, or a graphic option item; and audio
item formats. Examples of some question types can be
located throughout this chapter. In addition, the NGN
item types are provided on the accompanying Evolve
site.
As you read each chapter, identify your strengths and
areas that are in need of further review.
Test your strengths and abilities by answering all
practice questions provided in this book and on the
accompanying Evolve site. Be sure to read all rationales
and test-taking strategies. The rationale provides you
with signicant information regarding the correct and
incorrect options. The test-taking strategy provides you
with the logical path to selecting the correct option. A
reference source and page number are provided so that
you can easily nd information you need to review in
another Elsevier text. Each practice question on the
accompanying Evolve site is coded on the basis of the
Clinical Judgment and the Next Generation
NCLEX (NGN)-RN ® Examination
Linda A. Silvestri, PhD, RN, FAAN
Angela E. Silvestri, PhD, APRN, FNP-BC, CNE
C H A P T E R 1
Loading page 21...
Preparation
CHAPTER 1 Clinical Judgment and the Next Generation NCLEX (NGN)-RN ® Examination 3
Level of Cognitive Ability, the Client Needs category,
Clinical Judgment/Cognitive Skill, the Integrated Pro-
cess, the Content Area, the Health Problem if applica-
ble, and Priority Concepts. The Health Problem code is
a unique and helpful feature that allows you to lter and
select questions based on a disease process when you
are practicing questions on Evolve. For example, if heart
failure is your area of interest, you can select “Adult
Health, Cardiovascular, Heart Failure” on the Evolve
site, and all questions on this content will be gener-
ated for practice. In addition, two Priority Concepts that
relate to the content of the question are identied. This
code is especially helpful for students whose curriculum
is concept-based. Additionally, information about all
of the special features of this resource and the question
types is located in the preface of this book.
Other Resources in the Saunders Pyramid to Success
There are several other resources in the Saunders Pyra-
mid to Success program. These include the following:
The Saunders Q&A Review for the NCLEX-RN® Examina-
tion, The HESI/Saunders Online Review for the NCLEX-RN®
Examination, Saunders Clinical Judgment and Test-Taking
Strategies: Passing Nursing School and the NCLEX® Exam,
Strategies for Student Success on the Next Generation
NCLEX® (NGN) Test Items, Saunders Q&A Review Cards
for the NCLEX-RN® Exam, and Saunders RNtertainment
for the NCLEX-RN® Exam. The HESI® CompassTM Course
is also a resource for NCLEX preparation and provides
you with an individual coach to guide you in your prep-
aration. Ask your nursing instructors about institutional
access to this course.
The resources in the Saunders Pyramid to Success
are described in the preface of this book and can be
obtained online by visiting elsevierhealth.com or by
calling 800-545-2522.
Let’s begin our journey through the Pyramid to
Success.
Clinical Judgment and Next Generation
NCLEX ® Items
Clinical judgment is the observed outcome of critical
thinking and decision-making (Dickison, Haerling,
& Lasater, 2019). In recent years, heightened atten-
tion has been paid to clinical judgment as a means of
teaching, learning, and assessment and testing. The
Next Generation NCLEX-RN® examination requires
candidates to demonstrate a higher level of ability in
applying clinical judgment in the delivery of client care.
Clinical judgment can also be used as a test-taking strat-
egy to answer test questions (refer to Chapter 4). The
National Council of State Boards of Nursing (NCSBN)
has created a Clinical Judgment Measurement Model
(NCJMM) that consists of applying six cognitive skills
or processes. These include: (1) recognizing cues; (2)
analyzing cues; (3) prioritizing hypotheses; (4) gener-
ating solutions; (5) taking action; and (6) evaluating
outcomes (Dickison et al., 2019). Table 1.1 provides a
description of these six cognitive skills/processes identi-
ed in the NCJMM. The NCJMM also serves as a guide
for the NCSBN to create NGN® questions. The NCJMM
continues to evolve as may the NGN® item types that
will be presented in the exam. All of the current NCLEX
item types known as stand-alone items, the new clinical
judgment stand-alone items (bow-tie and trend), and
unfolding case studies that include six NGN items will
be presented in the NGN. Some of these new NGN®
item types can be found on the Evolve site accompany-
ing this book, and an example of a highlight-in-table
NGN item can be located in Chapter 4, Box 4.5. The
NCSBN conducts ongoing research on the NGN test
design and NGN items. The information in this chapter
reects what is currently published by the NCSBN. The
NGN will be implemented in April 2023 and because
some additional changes in item types may occur, we
encourage you to frequently access the NCSBN website
at www.ncsbn.org for updates about the NGN design,
items, and test plan updates.
Examination Process
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 exami-
nation can experience signicant anxiety. Knowing what
the examination is all about and knowing what you will
TABLE 1.1 Cognitive Skills/Processes and Descriptions
Cognitive Skill/Process Description
Recognize cues Identifying signicant data; data can be
from many sources (assessment)
Analyze cues Connecting data to the client's clinical
presentation—determining if the data is
expected? Unexpected? (analysis)
Prioritize hypotheses Ranking hypotheses; what are the
concerns or client needs/problems and
their priority? (analysis)
Generate solutions Using hypotheses or client needs to
determine interventions for an expected
outcome (planning)
Take action Implementing the generated solutions
addressing the highest priorities or
hypotheses (implementation)
Evaluate outcomes Comparing observed outcomes with
expected ones (evaluation)
From Dickison, P., Haerling, K.A., & Lasater, K. (2019). Integrating the
National Council of State Boards of Nursing Clinical Judgment Model
into Nursing Educational Frameworks. Journal of Nursing Education,
58(2), 72–78.
CHAPTER 1 Clinical Judgment and the Next Generation NCLEX (NGN)-RN ® Examination 3
Level of Cognitive Ability, the Client Needs category,
Clinical Judgment/Cognitive Skill, the Integrated Pro-
cess, the Content Area, the Health Problem if applica-
ble, and Priority Concepts. The Health Problem code is
a unique and helpful feature that allows you to lter and
select questions based on a disease process when you
are practicing questions on Evolve. For example, if heart
failure is your area of interest, you can select “Adult
Health, Cardiovascular, Heart Failure” on the Evolve
site, and all questions on this content will be gener-
ated for practice. In addition, two Priority Concepts that
relate to the content of the question are identied. This
code is especially helpful for students whose curriculum
is concept-based. Additionally, information about all
of the special features of this resource and the question
types is located in the preface of this book.
Other Resources in the Saunders Pyramid to Success
There are several other resources in the Saunders Pyra-
mid to Success program. These include the following:
The Saunders Q&A Review for the NCLEX-RN® Examina-
tion, The HESI/Saunders Online Review for the NCLEX-RN®
Examination, Saunders Clinical Judgment and Test-Taking
Strategies: Passing Nursing School and the NCLEX® Exam,
Strategies for Student Success on the Next Generation
NCLEX® (NGN) Test Items, Saunders Q&A Review Cards
for the NCLEX-RN® Exam, and Saunders RNtertainment
for the NCLEX-RN® Exam. The HESI® CompassTM Course
is also a resource for NCLEX preparation and provides
you with an individual coach to guide you in your prep-
aration. Ask your nursing instructors about institutional
access to this course.
The resources in the Saunders Pyramid to Success
are described in the preface of this book and can be
obtained online by visiting elsevierhealth.com or by
calling 800-545-2522.
Let’s begin our journey through the Pyramid to
Success.
Clinical Judgment and Next Generation
NCLEX ® Items
Clinical judgment is the observed outcome of critical
thinking and decision-making (Dickison, Haerling,
& Lasater, 2019). In recent years, heightened atten-
tion has been paid to clinical judgment as a means of
teaching, learning, and assessment and testing. The
Next Generation NCLEX-RN® examination requires
candidates to demonstrate a higher level of ability in
applying clinical judgment in the delivery of client care.
Clinical judgment can also be used as a test-taking strat-
egy to answer test questions (refer to Chapter 4). The
National Council of State Boards of Nursing (NCSBN)
has created a Clinical Judgment Measurement Model
(NCJMM) that consists of applying six cognitive skills
or processes. These include: (1) recognizing cues; (2)
analyzing cues; (3) prioritizing hypotheses; (4) gener-
ating solutions; (5) taking action; and (6) evaluating
outcomes (Dickison et al., 2019). Table 1.1 provides a
description of these six cognitive skills/processes identi-
ed in the NCJMM. The NCJMM also serves as a guide
for the NCSBN to create NGN® questions. The NCJMM
continues to evolve as may the NGN® item types that
will be presented in the exam. All of the current NCLEX
item types known as stand-alone items, the new clinical
judgment stand-alone items (bow-tie and trend), and
unfolding case studies that include six NGN items will
be presented in the NGN. Some of these new NGN®
item types can be found on the Evolve site accompany-
ing this book, and an example of a highlight-in-table
NGN item can be located in Chapter 4, Box 4.5. The
NCSBN conducts ongoing research on the NGN test
design and NGN items. The information in this chapter
reects what is currently published by the NCSBN. The
NGN will be implemented in April 2023 and because
some additional changes in item types may occur, we
encourage you to frequently access the NCSBN website
at www.ncsbn.org for updates about the NGN design,
items, and test plan updates.
Examination Process
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 exami-
nation can experience signicant anxiety. Knowing what
the examination is all about and knowing what you will
TABLE 1.1 Cognitive Skills/Processes and Descriptions
Cognitive Skill/Process Description
Recognize cues Identifying signicant data; data can be
from many sources (assessment)
Analyze cues Connecting data to the client's clinical
presentation—determining if the data is
expected? Unexpected? (analysis)
Prioritize hypotheses Ranking hypotheses; what are the
concerns or client needs/problems and
their priority? (analysis)
Generate solutions Using hypotheses or client needs to
determine interventions for an expected
outcome (planning)
Take action Implementing the generated solutions
addressing the highest priorities or
hypotheses (implementation)
Evaluate outcomes Comparing observed outcomes with
expected ones (evaluation)
From Dickison, P., Haerling, K.A., & Lasater, K. (2019). Integrating the
National Council of State Boards of Nursing Clinical Judgment Model
into Nursing Educational Frameworks. Journal of Nursing Education,
58(2), 72–78.
Loading page 22...
Preparation
UNIT I NCLEX-RN ® Exam Preparation4
encounter during the process of testing will assist in
alleviating fear and anxiety. The information contained
in this chapter was obtained from the NCSBN website
(www.ncsbn.org) and from the current NCSBN 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 regard-
ing the test and its development by accessing the NCSBN
website and clicking on the NCLEX Examination 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 the most up-
to-date and valuable information about the NCLEX and
other resources available to an NCLEX candidate. You
are also encouraged to access the most up-to-date Can-
didate Bulletin. This document provides you with every-
thing you need to know about registration procedures
and scheduling a test date.
Computer Adaptive Testing
The acronym CAT stands for computer adaptive test. The
exam is delivered as a variable length CAT, which allows
for the exam to select stand-alone items and item sets
(unfolding case studies) that are optimal for each test-
taker. The stand-alone items are selected and balanced
on the basis of the percentages of each of the test plan
categories and subcategories. Each item is selected to
target the candidate’s ability level. Once all test plan
requirements are met, a stopping rule is triggered in
which a reliable pass-or-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. Skip-
ping questions or returning to earlier questions is
incompatible with the logical methodology of a CAT.
The inability to skip questions or go back to change pre-
vious 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 unfa-
miliar 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 experi-
ences and clinical judgment skills 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 on
the NCSBN website, and you are encouraged to view the
online tutorial when you are preparing for the NCLEX
examination. The tutorial will instruct you on the use of
the on-screen optional calculator, the use of the mouse,
and how to record an answer. The tutorial also provides
instructions on how to respond to the different ques-
tion types on this examination. NCSBN also provides
an online tutorial about the new item types that allows
you to interact with these items as much as you need to
before taking the exam. 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.
The new NGN item types will not be scored as either
all correct or all incorrect. Instead, new scoring models
will be applied for new NGN items that allow partial
credit scoring for most items. For specic information
on the scoring models, refer to the NCSBN website at
www.ncsbn.org and the National Council of State Boards
of Nursing’s Next Generation NCLEX News (2021) at
https://www.ncsbn.org/NGN_Summer21_Eng.pdf.
Development of the Test Plan
The test plan for the NCLEX-RN examination is devel-
oped by the NCSBN. The examination is a national
examination; the NCSBN considers the legal scope of
nursing practice as governed by state laws and regula-
tions, including the nurse practice act, and uses these
laws to dene 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 link the
examination to nursing practice. The results of this
study determine the framework for the test plan for
the examination. The participants in this study include
newly licensed registered nurses from all types of gen-
eralist nursing education programs. Participants of this
study provide valuable information about work settings.
From a list of nursing care activities (activity statements)
provided, the participants are asked about the applica-
bility, frequency, and importance of performing these
activities in relation to client safety. A panel of content
experts at the NCSBN analyzes the results of the study
and makes decisions regarding the test plan framework.
The NCSBN also conducted extensive research and
experimentation and sought out subject matter expert
feedback from educators, researchers, and practicing clin-
ical nurses about clinical experiences and health prob-
lems commonly encountered by a new graduate nurse.
Findings supported the need for developing a model for
measuring clinical judgment in the test plan design. This
led to the development of new NGN test items and con-
tinuous research to test item reliability and validity.
UNIT I NCLEX-RN ® Exam Preparation4
encounter during the process of testing will assist in
alleviating fear and anxiety. The information contained
in this chapter was obtained from the NCSBN website
(www.ncsbn.org) and from the current NCSBN 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 regard-
ing the test and its development by accessing the NCSBN
website and clicking on the NCLEX Examination 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 the most up-
to-date and valuable information about the NCLEX and
other resources available to an NCLEX candidate. You
are also encouraged to access the most up-to-date Can-
didate Bulletin. This document provides you with every-
thing you need to know about registration procedures
and scheduling a test date.
Computer Adaptive Testing
The acronym CAT stands for computer adaptive test. The
exam is delivered as a variable length CAT, which allows
for the exam to select stand-alone items and item sets
(unfolding case studies) that are optimal for each test-
taker. The stand-alone items are selected and balanced
on the basis of the percentages of each of the test plan
categories and subcategories. Each item is selected to
target the candidate’s ability level. Once all test plan
requirements are met, a stopping rule is triggered in
which a reliable pass-or-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. Skip-
ping questions or returning to earlier questions is
incompatible with the logical methodology of a CAT.
The inability to skip questions or go back to change pre-
vious 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 unfa-
miliar 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 experi-
ences and clinical judgment skills 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 on
the NCSBN website, and you are encouraged to view the
online tutorial when you are preparing for the NCLEX
examination. The tutorial will instruct you on the use of
the on-screen optional calculator, the use of the mouse,
and how to record an answer. The tutorial also provides
instructions on how to respond to the different ques-
tion types on this examination. NCSBN also provides
an online tutorial about the new item types that allows
you to interact with these items as much as you need to
before taking the exam. 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.
The new NGN item types will not be scored as either
all correct or all incorrect. Instead, new scoring models
will be applied for new NGN items that allow partial
credit scoring for most items. For specic information
on the scoring models, refer to the NCSBN website at
www.ncsbn.org and the National Council of State Boards
of Nursing’s Next Generation NCLEX News (2021) at
https://www.ncsbn.org/NGN_Summer21_Eng.pdf.
Development of the Test Plan
The test plan for the NCLEX-RN examination is devel-
oped by the NCSBN. The examination is a national
examination; the NCSBN considers the legal scope of
nursing practice as governed by state laws and regula-
tions, including the nurse practice act, and uses these
laws to dene 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 link the
examination to nursing practice. The results of this
study determine the framework for the test plan for
the examination. The participants in this study include
newly licensed registered nurses from all types of gen-
eralist nursing education programs. Participants of this
study provide valuable information about work settings.
From a list of nursing care activities (activity statements)
provided, the participants are asked about the applica-
bility, frequency, and importance of performing these
activities in relation to client safety. A panel of content
experts at the NCSBN analyzes the results of the study
and makes decisions regarding the test plan framework.
The NCSBN also conducted extensive research and
experimentation and sought out subject matter expert
feedback from educators, researchers, and practicing clin-
ical nurses about clinical experiences and health prob-
lems commonly encountered by a new graduate nurse.
Findings supported the need for developing a model for
measuring clinical judgment in the test plan design. This
led to the development of new NGN test items and con-
tinuous research to test item reliability and validity.
Loading page 23...
Preparation
CHAPTER 1 Clinical Judgment and the Next Generation NCLEX (NGN)-RN ® Examination 5
Test Plan
The questions are written to address Level of Cognitive
Ability, Client Needs, and Integrated Processes, includ-
ing Clinical Judgment and Cognitive Skills, as identied
in the test plan developed by the NCSBN.
The content of the NCLEX-RN examination reects
the activities identied in the practice analysis study
conducted by the NCSBN. Exam items are written based
on the test plan framework and these activities rather
than on content areas such as adult health, maternity,
pediatrics, or mental health.
Level of Cognitive Ability
Levels of cognitive ability include remembering, under-
standing, applying, analyzing, evaluating, and creating.
The practice of nursing requires complex thought pro-
cessing and critical thinking in decision making and
in making clinical judgments. Therefore, you will not
encounter any remembering or understanding questions
on the NCLEX. Questions on this examination are writ-
ten at the applying level or higher in terms of cognitive
ability. Table 1.2 provides descriptions and examples of
each level of cognitive ability. Box 1.1 presents an exam-
ple of a question that requires you to apply data.
Client Needs
The NCSBN identies a test plan framework based on
Client Needs, which includes four major categories.
Some of these categories are divided further into sub-
categories. The Client Needs categories are Safe and
Effective Care Environment, Health Promotion and
Maintenance, Psychosocial Integrity, and Physiological
Integrity (Table 1.3).
Safe and Effective Care Environment
The Safe and Effective Care Environment category
includes two subcategories: Management of Care,
and Safety and Infection Control. According to the
NCSBN, Management of Care addresses prioritizing
care and providing and directing nursing care that
will ensure a safe care delivery setting to protect cli-
ents and health care personnel. The NCSBN indicates
that Safety and Infection Control addresses content
that will protect clients 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 two
subcategories.
Health Promotion and Maintenance
The Health Promotion and Maintenance category
addresses the principles related to growth and devel-
opment. According to the NCSBN, this Client Needs
category also addresses content required to assist the
individual to prevent health problems; to recognize
alterations in health; and to develop health practices
that promote and support optimal wellness. See Box
1.3 for an example of a question in this Client Needs
category.
Psychosocial Integrity
The Psychosocial Integrity category addresses content
required to promote and support the ability of the cli-
ent to cope, adapt, and problem-solve during stressful
events. The NCSBN also indicates that this Client Needs
category addresses the emotional, mental, and social
well-being of the client experiencing stressful events and
care for the client with an acute or chronic mental ill-
ness. See Box 1.4 for an example of a question in this
Client Needs category.
TABLE 1.2 Levels of Cognitive Ability: Level and
Descriptions and Examples
Level Description and Example
Remembering Recalling, retrieving information from memoriza-
tion, previous learning, or long-term memory.
Example: A normal blood glucose level is 70-99
mg/dL (3.9-5.5 mmol/L).
Understanding Determining the meaning of information.
Example: A blood glucose level of 60 mg/dL (3.34
mmol/L) is lower than the normal reference range.
Applying Carrying out an appropriate action based on
information.
Example: Administering 10–15 g of carbohydrate
such as a ½ glass of fruit juice to treat mild hypo-
glycemia.
Analyzing Examining concepts or data and interpreting how
the concepts or data connect or relate to one
another.
Example: The concept is mild hypoglycemia and
the connecting data are the signs and symptoms
of mild hypoglycemia, such as hunger, irritability,
weakness, headache, blood glucose level lower
than 60 mg/dL (3.34 mmol/L).
Evaluating Making judgments, conclusions, or validations
based on evidence.
Example: Determining that treatment for mild
hypoglycemia was eective if the blood glucose level
returned to a normal level between 70-99 mg/dL
(3.9-5.5 mmol/L) and signs and symptoms resolved.
Creating Generating or producing a new outcome or plan of
care by putting parts of information together.
Example: Designing a safe and individualized plan
of care with the interprofessional health care team
for a client with diabetes mellitus that meets the
client’s physiological, psychosocial, and health
maintenance needs.
Adapted from Understanding Bloom’s (and Anderson and Krathwohl’s)
Taxonomy, 2015, ProEdit, Inc. http://www.proedit.com/understanding-
blooms-and-anderson-and-krathwohls-taxonomy/
CHAPTER 1 Clinical Judgment and the Next Generation NCLEX (NGN)-RN ® Examination 5
Test Plan
The questions are written to address Level of Cognitive
Ability, Client Needs, and Integrated Processes, includ-
ing Clinical Judgment and Cognitive Skills, as identied
in the test plan developed by the NCSBN.
The content of the NCLEX-RN examination reects
the activities identied in the practice analysis study
conducted by the NCSBN. Exam items are written based
on the test plan framework and these activities rather
than on content areas such as adult health, maternity,
pediatrics, or mental health.
Level of Cognitive Ability
Levels of cognitive ability include remembering, under-
standing, applying, analyzing, evaluating, and creating.
The practice of nursing requires complex thought pro-
cessing and critical thinking in decision making and
in making clinical judgments. Therefore, you will not
encounter any remembering or understanding questions
on the NCLEX. Questions on this examination are writ-
ten at the applying level or higher in terms of cognitive
ability. Table 1.2 provides descriptions and examples of
each level of cognitive ability. Box 1.1 presents an exam-
ple of a question that requires you to apply data.
Client Needs
The NCSBN identies a test plan framework based on
Client Needs, which includes four major categories.
Some of these categories are divided further into sub-
categories. The Client Needs categories are Safe and
Effective Care Environment, Health Promotion and
Maintenance, Psychosocial Integrity, and Physiological
Integrity (Table 1.3).
Safe and Effective Care Environment
The Safe and Effective Care Environment category
includes two subcategories: Management of Care,
and Safety and Infection Control. According to the
NCSBN, Management of Care addresses prioritizing
care and providing and directing nursing care that
will ensure a safe care delivery setting to protect cli-
ents and health care personnel. The NCSBN indicates
that Safety and Infection Control addresses content
that will protect clients 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 two
subcategories.
Health Promotion and Maintenance
The Health Promotion and Maintenance category
addresses the principles related to growth and devel-
opment. According to the NCSBN, this Client Needs
category also addresses content required to assist the
individual to prevent health problems; to recognize
alterations in health; and to develop health practices
that promote and support optimal wellness. See Box
1.3 for an example of a question in this Client Needs
category.
Psychosocial Integrity
The Psychosocial Integrity category addresses content
required to promote and support the ability of the cli-
ent to cope, adapt, and problem-solve during stressful
events. The NCSBN also indicates that this Client Needs
category addresses the emotional, mental, and social
well-being of the client experiencing stressful events and
care for the client with an acute or chronic mental ill-
ness. See Box 1.4 for an example of a question in this
Client Needs category.
TABLE 1.2 Levels of Cognitive Ability: Level and
Descriptions and Examples
Level Description and Example
Remembering Recalling, retrieving information from memoriza-
tion, previous learning, or long-term memory.
Example: A normal blood glucose level is 70-99
mg/dL (3.9-5.5 mmol/L).
Understanding Determining the meaning of information.
Example: A blood glucose level of 60 mg/dL (3.34
mmol/L) is lower than the normal reference range.
Applying Carrying out an appropriate action based on
information.
Example: Administering 10–15 g of carbohydrate
such as a ½ glass of fruit juice to treat mild hypo-
glycemia.
Analyzing Examining concepts or data and interpreting how
the concepts or data connect or relate to one
another.
Example: The concept is mild hypoglycemia and
the connecting data are the signs and symptoms
of mild hypoglycemia, such as hunger, irritability,
weakness, headache, blood glucose level lower
than 60 mg/dL (3.34 mmol/L).
Evaluating Making judgments, conclusions, or validations
based on evidence.
Example: Determining that treatment for mild
hypoglycemia was eective if the blood glucose level
returned to a normal level between 70-99 mg/dL
(3.9-5.5 mmol/L) and signs and symptoms resolved.
Creating Generating or producing a new outcome or plan of
care by putting parts of information together.
Example: Designing a safe and individualized plan
of care with the interprofessional health care team
for a client with diabetes mellitus that meets the
client’s physiological, psychosocial, and health
maintenance needs.
Adapted from Understanding Bloom’s (and Anderson and Krathwohl’s)
Taxonomy, 2015, ProEdit, Inc. http://www.proedit.com/understanding-
blooms-and-anderson-and-krathwohls-taxonomy/
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Preparation
UNIT I NCLEX-RN ® Exam Preparation6
Physiological Integrity
The Physiological Integrity category includes four sub-
categories: Basic Care and Comfort, Pharmacological
and Parenteral Therapies, Reduction of Risk Potential,
and Physiological Adaptation. The NCSBN describes
these subcategories as follows: Basic Care and Comfort
addresses content for providing comfort and assistance
to the client in the performance of activities of daily liv-
ing. Pharmacological and Parenteral Therapies addresses
content for administering medications and parenteral
therapies, such as intravenous therapies and parenteral
nutrition, and administering blood and blood prod-
ucts. Reduction of Risk Potential addresses content for
The nurse notes blanching, coolness, and edema at the
peripheral intravenous (IV) site. On the basis of these nd-
ings, the nurse would implement which action rst?
1. Remove the IV.
2. Apply a warm compress.
3. Check for a blood return.
4. Measure the area of inltration.
Answer: 1
This question requires that you focus on the data in the ques-
tion and analyze that data to determine that the client is expe-
riencing an inltration. Note the strategic word, rst. Next, you
need to consider the harmful effects of inltration and deter-
mine the action to implement rst. Because inltration can
be damaging to the surrounding tissue, the appropriate rst
action is to remove the IV to prevent further damage. Once
the IV is removed, further action would be taken, depend-
ing on the medication infusing at the time of inltration and
based on agency protocol. Further action may include aspira-
tion of the uid from the site, injection of an antidote, applica-
tion of warm or cool compresses for specied time intervals,
or elevation of the extremity.
BOX 1.1 Level of Cognitive Ability: Applying
TABLE 1.3 The Client Needs Categories and
Subcategories and Percentage of Questions on the
NCLEX-RN Examination
Client Needs Category and Subcategory
Percentage of
Questions
Safe and Eective Care Environment
Management of Care 17-23
Safety and Infection Control 9-15
Health Promotion and Maintenance 6-12
Psychosocial Integrity 6-12
Physiological Integrity
Basic Care and Comfort 6-12
Pharmacological and Parenteral Therapies 12-18
Reduction of Risk Potential 9-15
Physiological Adaptation 11-17
From National Council of State Boards of Nursing: 2019 NCLEX-RN ®
examination: Test plan for the National Council Licensure Examination for
Registered Nurses. Chicago, 2018, National Council of State Boards of
Nursing.
Management of Care
The nurse has received the client assignment for the day.
Which client would the nurse assess first?
1. The client who has a nasogastric tube attached to inter-
mittent suction
2. The client who needs to receive subcutaneous insulin
before breakfast
3. The client who is 2 days postoperative and is complain-
ing of incisional pain
4. The client who has a blood glucose level of 50 mg/dL
(2.8 mmol/L) and complains of blurred vision
Answer: 4
This question addresses the subcategory Management of
Care in the Client Needs category Safe and Effective Care
Environment. Note the strategic word, rst, 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 low blood glucose level and symptoms
reective of hypoglycemia. This client should be assessed rst
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
stabilized.
Safety and Infection Control
The nurse prepares to care for a client on contact precau-
tions who has a hospital-acquired infection caused by
methicillin-resistant Staphylococcus aureus (MRSA). The
client has an abdominal wound that requires irrigation
and has a tracheostomy attached to a mechanical ventila-
tor, which requires frequent suctioning. The nurse would
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
Answer: 3
This question addresses the subcategory Safety and Infec-
tion 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. Note the data in the ques-
tion. Because of the potential for splashes of infective mate-
rial occurring during the wound irrigation or suctioning of the
tracheostomy, option 3 is correct.
BOX 1.2 Safe and Effective Care Environment
UNIT I NCLEX-RN ® Exam Preparation6
Physiological Integrity
The Physiological Integrity category includes four sub-
categories: Basic Care and Comfort, Pharmacological
and Parenteral Therapies, Reduction of Risk Potential,
and Physiological Adaptation. The NCSBN describes
these subcategories as follows: Basic Care and Comfort
addresses content for providing comfort and assistance
to the client in the performance of activities of daily liv-
ing. Pharmacological and Parenteral Therapies addresses
content for administering medications and parenteral
therapies, such as intravenous therapies and parenteral
nutrition, and administering blood and blood prod-
ucts. Reduction of Risk Potential addresses content for
The nurse notes blanching, coolness, and edema at the
peripheral intravenous (IV) site. On the basis of these nd-
ings, the nurse would implement which action rst?
1. Remove the IV.
2. Apply a warm compress.
3. Check for a blood return.
4. Measure the area of inltration.
Answer: 1
This question requires that you focus on the data in the ques-
tion and analyze that data to determine that the client is expe-
riencing an inltration. Note the strategic word, rst. Next, you
need to consider the harmful effects of inltration and deter-
mine the action to implement rst. Because inltration can
be damaging to the surrounding tissue, the appropriate rst
action is to remove the IV to prevent further damage. Once
the IV is removed, further action would be taken, depend-
ing on the medication infusing at the time of inltration and
based on agency protocol. Further action may include aspira-
tion of the uid from the site, injection of an antidote, applica-
tion of warm or cool compresses for specied time intervals,
or elevation of the extremity.
BOX 1.1 Level of Cognitive Ability: Applying
TABLE 1.3 The Client Needs Categories and
Subcategories and Percentage of Questions on the
NCLEX-RN Examination
Client Needs Category and Subcategory
Percentage of
Questions
Safe and Eective Care Environment
Management of Care 17-23
Safety and Infection Control 9-15
Health Promotion and Maintenance 6-12
Psychosocial Integrity 6-12
Physiological Integrity
Basic Care and Comfort 6-12
Pharmacological and Parenteral Therapies 12-18
Reduction of Risk Potential 9-15
Physiological Adaptation 11-17
From National Council of State Boards of Nursing: 2019 NCLEX-RN ®
examination: Test plan for the National Council Licensure Examination for
Registered Nurses. Chicago, 2018, National Council of State Boards of
Nursing.
Management of Care
The nurse has received the client assignment for the day.
Which client would the nurse assess first?
1. The client who has a nasogastric tube attached to inter-
mittent suction
2. The client who needs to receive subcutaneous insulin
before breakfast
3. The client who is 2 days postoperative and is complain-
ing of incisional pain
4. The client who has a blood glucose level of 50 mg/dL
(2.8 mmol/L) and complains of blurred vision
Answer: 4
This question addresses the subcategory Management of
Care in the Client Needs category Safe and Effective Care
Environment. Note the strategic word, rst, 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 low blood glucose level and symptoms
reective of hypoglycemia. This client should be assessed rst
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
stabilized.
Safety and Infection Control
The nurse prepares to care for a client on contact precau-
tions who has a hospital-acquired infection caused by
methicillin-resistant Staphylococcus aureus (MRSA). The
client has an abdominal wound that requires irrigation
and has a tracheostomy attached to a mechanical ventila-
tor, which requires frequent suctioning. The nurse would
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
Answer: 3
This question addresses the subcategory Safety and Infec-
tion 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. Note the data in the ques-
tion. Because of the potential for splashes of infective mate-
rial occurring during the wound irrigation or suctioning of the
tracheostomy, option 3 is correct.
BOX 1.2 Safe and Effective Care Environment
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Preparation
CHAPTER 1 Clinical Judgment and the Next Generation NCLEX (NGN)-RN ® Examination 7
preventing complications or health problems related to
the client’s condition or any prescribed treatments or
procedures. Physiological Adaptation addresses content
for managing and providing care to clients with acute,
chronic, or life-threatening conditions. See Box 1.5 for
examples of questions in this Client Needs category.
Integrated Processes
The NCSBN identies ve processes in the test plan that
are fundamental to the practice of nursing. These pro-
cesses are incorporated throughout the major categories
of Client Needs. The Integrated Process subcategories are
Caring, Communication and Documentation, Nursing
Process (Assessment, Analysis, Planning, Implementa-
tion, and Evaluation), Culture and Spirituality, and Teach-
ing 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
and Scoring
The types of questions on the current NCLEX include
multiple-choice; ll-in-the-blank; multiple-response;
ordered-response (prioritizing); image (hot spot) ques-
tions; gure, chart/exhibit, or graphic option items; and
audio formats. These question types will continue to
be a part of the NCLEX examination, and each of these
question types will be scored as either correct or incor-
rect, known as dichotomous scoring. Currently, no partial
credit is given. Thus, the possible points for these ques-
tion types will be 0 or 1 point. Examples of these ques-
tion types follow.
The NGN question types will also be on the exam,
starting in April 2023, and will use a case study approach
as stand-alone items and unfolding case studies. The
stand-alone items will be accompanied by a question that
tests more than one cognitive skill. Each unfolding case
study will be accompanied by six NGN item type ques-
tions, and each cognitive skill will be tested. Every can-
didate will be administered three unfolding case studies,
each with six accompanying items. These three unfold-
ing case studies will be administered within the rst 85
questions on the exam (minimum length exam). After
the minimum-length exam, if a stopping rule is not trig-
gered, then the exam will continue and stand-alone items
(bow-tie and trend) will be administered as part of the
exam. Examples of both stand-alone items and unfold-
ing case studies and NGN items can be located on the
Evolve site accompanying this book. These are specially
designed to simulate the NCLEX experience of testing for
these NGN item types. Both NGN stand-alone items (cur-
rently known as bow-tie and trend) and unfolding cases
with accompanying NGN items are included. Refer to the
Evolve site for practice with these question types. Addi-
tionally, the unique test-taking strategies used to answer
NGN items are illustrated with each bow-tie and trend
item and with items accompanying the unfolding case
studies. Chapter 4, Box 4.5 provides an example of one
type of NGN question and its unique test-taking strategy.
In addition to the stand-alone items (bow-tie and
trend), according to the NCSBN, other NGN item types
will be used. Table 1.4 provides a list of the NGN ques-
tion types. The NCSBN also identies three scoring
methods for NGN items. These scoring methods are
described in Table 1.5
The NCSBN provides specic directions for you to
follow with all question types on the NCLEX to guide
you through the testing process. Be sure to read these
directions as they appear on the computer screen.
The nurse is choosing age-appropriate toys for a toddler.
Which toy is the best choice for this age?
1. Puzzle
2. Toy soldiers
3. Large stacking blocks
4. A card game with large pictures
Answer: 3
This question addresses the Client Needs category Health
Promotion and Maintenance and specically relates to the
principles of growth and development of a toddler. Note the
strategic word, best. Toddlers like to master activities inde-
pendently, 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 pic-
tures may require cooperative play, which is more appropriate
for a school-age child.
BOX 1.3 Health Promotion and Maintenance
A client with end-stage chronic obstructive pulmonary disease
has selected guided imagery to help cope with psychological
stress. Which client statement indicates the best understand-
ing of this stress-reduction measure?
1. “This will help only if I play music at the same time.”
2. “This will work for me if I am alone in a quiet area.”
3. “I need to do this when I lie down in case I fall asleep.”
4. “The best thing about this is that I can use it anywhere,
anytime.”
Answer: 4
This question addresses the Client Needs category Psychoso-
cial Integrity, and the content addresses coping mechanisms.
Note the strategic word, best. Focus on the subject, a charac-
teristic of guided imagery. 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.
BOX 1.4 Psychosocial Integrity
CHAPTER 1 Clinical Judgment and the Next Generation NCLEX (NGN)-RN ® Examination 7
preventing complications or health problems related to
the client’s condition or any prescribed treatments or
procedures. Physiological Adaptation addresses content
for managing and providing care to clients with acute,
chronic, or life-threatening conditions. See Box 1.5 for
examples of questions in this Client Needs category.
Integrated Processes
The NCSBN identies ve processes in the test plan that
are fundamental to the practice of nursing. These pro-
cesses are incorporated throughout the major categories
of Client Needs. The Integrated Process subcategories are
Caring, Communication and Documentation, Nursing
Process (Assessment, Analysis, Planning, Implementa-
tion, and Evaluation), Culture and Spirituality, and Teach-
ing 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
and Scoring
The types of questions on the current NCLEX include
multiple-choice; ll-in-the-blank; multiple-response;
ordered-response (prioritizing); image (hot spot) ques-
tions; gure, chart/exhibit, or graphic option items; and
audio formats. These question types will continue to
be a part of the NCLEX examination, and each of these
question types will be scored as either correct or incor-
rect, known as dichotomous scoring. Currently, no partial
credit is given. Thus, the possible points for these ques-
tion types will be 0 or 1 point. Examples of these ques-
tion types follow.
The NGN question types will also be on the exam,
starting in April 2023, and will use a case study approach
as stand-alone items and unfolding case studies. The
stand-alone items will be accompanied by a question that
tests more than one cognitive skill. Each unfolding case
study will be accompanied by six NGN item type ques-
tions, and each cognitive skill will be tested. Every can-
didate will be administered three unfolding case studies,
each with six accompanying items. These three unfold-
ing case studies will be administered within the rst 85
questions on the exam (minimum length exam). After
the minimum-length exam, if a stopping rule is not trig-
gered, then the exam will continue and stand-alone items
(bow-tie and trend) will be administered as part of the
exam. Examples of both stand-alone items and unfold-
ing case studies and NGN items can be located on the
Evolve site accompanying this book. These are specially
designed to simulate the NCLEX experience of testing for
these NGN item types. Both NGN stand-alone items (cur-
rently known as bow-tie and trend) and unfolding cases
with accompanying NGN items are included. Refer to the
Evolve site for practice with these question types. Addi-
tionally, the unique test-taking strategies used to answer
NGN items are illustrated with each bow-tie and trend
item and with items accompanying the unfolding case
studies. Chapter 4, Box 4.5 provides an example of one
type of NGN question and its unique test-taking strategy.
In addition to the stand-alone items (bow-tie and
trend), according to the NCSBN, other NGN item types
will be used. Table 1.4 provides a list of the NGN ques-
tion types. The NCSBN also identies three scoring
methods for NGN items. These scoring methods are
described in Table 1.5
The NCSBN provides specic directions for you to
follow with all question types on the NCLEX to guide
you through the testing process. Be sure to read these
directions as they appear on the computer screen.
The nurse is choosing age-appropriate toys for a toddler.
Which toy is the best choice for this age?
1. Puzzle
2. Toy soldiers
3. Large stacking blocks
4. A card game with large pictures
Answer: 3
This question addresses the Client Needs category Health
Promotion and Maintenance and specically relates to the
principles of growth and development of a toddler. Note the
strategic word, best. Toddlers like to master activities inde-
pendently, 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 pic-
tures may require cooperative play, which is more appropriate
for a school-age child.
BOX 1.3 Health Promotion and Maintenance
A client with end-stage chronic obstructive pulmonary disease
has selected guided imagery to help cope with psychological
stress. Which client statement indicates the best understand-
ing of this stress-reduction measure?
1. “This will help only if I play music at the same time.”
2. “This will work for me if I am alone in a quiet area.”
3. “I need to do this when I lie down in case I fall asleep.”
4. “The best thing about this is that I can use it anywhere,
anytime.”
Answer: 4
This question addresses the Client Needs category Psychoso-
cial Integrity, and the content addresses coping mechanisms.
Note the strategic word, best. Focus on the subject, a charac-
teristic of guided imagery. 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.
BOX 1.4 Psychosocial Integrity
Loading page 26...
Preparation
UNIT I NCLEX-RN ® Exam Preparation8
Examples of some of these types of questions are noted
in this chapter and in this book, and all types, including
the NGN items, are on the accompanying Evolve site.
Multiple-Choice Questions
Some 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 situ-
ation and four answers, or options. Only one answer
is correct.
Fill-in-the-Blank Questions
Fill-in-the-blank questions will ask you to perform a
medication calculation, determine an intravenous ow
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 cal-
culation. The rules for rounding an answer are described
in the tutorial provided by the NCSBN and are also pro-
vided in the specic question on the computer screen.
Basic Care and Comfort
A client with Parkinson’s disease develops akinesia while ambu-
lating, increasing the risk for falls. Which suggestion would 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
walker.
4. Consciously think about walking over imaginary lines on
the oor.
Answer: 4
This question addresses the subcategory Basic Care and Com-
fort in the Client Needs category Physiological Integrity and
addresses client mobility and promoting assistance in an activ-
ity of daily living to maintain safety. Focus on the subject, akine-
sia. Clients with Parkinson’s disease can develop bradykinesia
(slow movement) or akinesia (freezing or no movement). Hav-
ing these clients imagine lines on the oor to walk over can
keep them moving forward while remaining safe.
Pharmacological and Parenteral Therapies
The nurse monitors a client receiving digoxin for which early
manifestation of digoxin toxicity?
1. Anorexia
2. Facial pain
3. Photophobia
4. Yellow color perception
Answer: 1
This question addresses the subcategory Pharmacological and
Parenteral Therapies in the Client Needs category Physiologi-
cal Integrity. Note the strategic word, early. Digoxin is a cardiac
glycoside that is used to manage and treat heart failure in some
clients and to control ventricular rates in some clients with atrial
brillation. The most common early manifestations of toxicity
include gastrointestinal disturbances such as anorexia, nau-
sea, and vomiting. Neurological abnormalities can also occur
early and include fatigue, headache, weakness, depression,
drowsiness, confusion, and nightmares. Facial pain, personal-
ity changes, and ocular disturbances (photophobia, diplopia,
light ashes, 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 would imple-
ment 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 (nothing by mouth) for 6 hours be-
fore the test.
4. Instruct the client in inhalation techniques for the admin-
istration of a radioisotope.
Answer: 2
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 to prevent risks associated with the test. Focus
on the subject, preparing a client for an MRI. In an MRI study,
radiofrequency pulses in a magnetic eld are converted into
pictures. All metal objects, such as rings, bracelets, hairpins,
and watches, should be removed. In addition, a history should
be taken to ascertain whether the client has any internal metal-
lic devices, such as orthopedic hardware, pacemakers, or
shrapnel. An intravenous (IV) catheter may be inserted if a con-
trast agent is prescribed. A femoral catheter is not used for this
diagnostic test. Additionally, shaving is not a common practice
because of the risk for microabrasions and infection. If needed,
hair may be clipped away from an insertion site. NPO status
is not necessary for an MRI study of the head. Inhalation of a
radioisotope may be prescribed with other types of scans, but it
is not a part of the procedures for an MRI.
Physiological Adaptation
A client with renal insufciency has a magnesium level of 3.5
mEq/L (1.44 mmol/L). On the basis of this laboratory result,
the nurse interprets which sign as signicant?
1. Hyperpnea
2. Drowsiness
3. Hypertension
4. Physical hyperactivity
Answer: 2
This question addresses the subcategory Physiological Adap-
tation in the Client Needs category Physiological Integrity. It
addresses an alteration in body systems. Focus on the data in
the question. The normal magnesium level is 1.8 to 2.6 mEq/L
(0.74 to 1.07 mmol/L). A magnesium level of 3.5 mEq/L (1.44
mmol/L) indicates hypermagnesemia. Neurological manifesta-
tions 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 areexia. Bradycardia and hypotension also
occur.
BOX 1.5 Physiological Integrity
UNIT I NCLEX-RN ® Exam Preparation8
Examples of some of these types of questions are noted
in this chapter and in this book, and all types, including
the NGN items, are on the accompanying Evolve site.
Multiple-Choice Questions
Some 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 situ-
ation and four answers, or options. Only one answer
is correct.
Fill-in-the-Blank Questions
Fill-in-the-blank questions will ask you to perform a
medication calculation, determine an intravenous ow
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 cal-
culation. The rules for rounding an answer are described
in the tutorial provided by the NCSBN and are also pro-
vided in the specic question on the computer screen.
Basic Care and Comfort
A client with Parkinson’s disease develops akinesia while ambu-
lating, increasing the risk for falls. Which suggestion would 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
walker.
4. Consciously think about walking over imaginary lines on
the oor.
Answer: 4
This question addresses the subcategory Basic Care and Com-
fort in the Client Needs category Physiological Integrity and
addresses client mobility and promoting assistance in an activ-
ity of daily living to maintain safety. Focus on the subject, akine-
sia. Clients with Parkinson’s disease can develop bradykinesia
(slow movement) or akinesia (freezing or no movement). Hav-
ing these clients imagine lines on the oor to walk over can
keep them moving forward while remaining safe.
Pharmacological and Parenteral Therapies
The nurse monitors a client receiving digoxin for which early
manifestation of digoxin toxicity?
1. Anorexia
2. Facial pain
3. Photophobia
4. Yellow color perception
Answer: 1
This question addresses the subcategory Pharmacological and
Parenteral Therapies in the Client Needs category Physiologi-
cal Integrity. Note the strategic word, early. Digoxin is a cardiac
glycoside that is used to manage and treat heart failure in some
clients and to control ventricular rates in some clients with atrial
brillation. The most common early manifestations of toxicity
include gastrointestinal disturbances such as anorexia, nau-
sea, and vomiting. Neurological abnormalities can also occur
early and include fatigue, headache, weakness, depression,
drowsiness, confusion, and nightmares. Facial pain, personal-
ity changes, and ocular disturbances (photophobia, diplopia,
light ashes, 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 would imple-
ment 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 (nothing by mouth) for 6 hours be-
fore the test.
4. Instruct the client in inhalation techniques for the admin-
istration of a radioisotope.
Answer: 2
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 to prevent risks associated with the test. Focus
on the subject, preparing a client for an MRI. In an MRI study,
radiofrequency pulses in a magnetic eld are converted into
pictures. All metal objects, such as rings, bracelets, hairpins,
and watches, should be removed. In addition, a history should
be taken to ascertain whether the client has any internal metal-
lic devices, such as orthopedic hardware, pacemakers, or
shrapnel. An intravenous (IV) catheter may be inserted if a con-
trast agent is prescribed. A femoral catheter is not used for this
diagnostic test. Additionally, shaving is not a common practice
because of the risk for microabrasions and infection. If needed,
hair may be clipped away from an insertion site. NPO status
is not necessary for an MRI study of the head. Inhalation of a
radioisotope may be prescribed with other types of scans, but it
is not a part of the procedures for an MRI.
Physiological Adaptation
A client with renal insufciency has a magnesium level of 3.5
mEq/L (1.44 mmol/L). On the basis of this laboratory result,
the nurse interprets which sign as signicant?
1. Hyperpnea
2. Drowsiness
3. Hypertension
4. Physical hyperactivity
Answer: 2
This question addresses the subcategory Physiological Adap-
tation in the Client Needs category Physiological Integrity. It
addresses an alteration in body systems. Focus on the data in
the question. The normal magnesium level is 1.8 to 2.6 mEq/L
(0.74 to 1.07 mmol/L). A magnesium level of 3.5 mEq/L (1.44
mmol/L) indicates hypermagnesemia. Neurological manifesta-
tions 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 areexia. Bradycardia and hypotension also
occur.
BOX 1.5 Physiological Integrity
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Preparation
CHAPTER 1 Clinical Judgment and the Next Generation NCLEX (NGN)-RN ® Examination 9
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 proce-
dure?”
2. “Your fears are a sign that you really should have this
procedure.”
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 proce-
dure for the cardiologist.”
Answer: 1
This question addresses the subcategory Caring in the cat-
egory of Integrated Processes. It also addresses the concept
of communication. The correct option utilizes a therapeutic
communication technique that explores the client’s feelings,
determines the level of client understanding about the proce-
dure, 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 reassur-
ance, and puts the client’s feelings on hold. Option 4 dimin-
ishes the client’s feelings by directing attention away from the
client and toward the cardiologist’s importance.
BOX 1.6 Integrated Processes
TABLE 1.4 NGN Item Types
Type of
Item/Case
Scenario Description Item Types
Stand-alone
Item
A stand-alone item
will include a short
scenario about a client
and will be accompa-
nied by one question
that tests more than
one cognitive skill.
Bow-tie
Trend
Unfolding
Case
An unfolding case
study will include
phases as the story
about the client un-
folds and changes.
This will be accom-
panied by six NGN
item type questions,
and each of the six
cognitive skills will be
tested.
Highlight in Text
Highlight in Table
Matrix Multiple Choice
Matrix Multiple Response
Multiple Response Select
N
Multiple Response Select
All That Apply
Multiple Response Group-
ing
Drag and Drop Cloze
Drag and Drop Rationale
Drop Down Cloze
Drop Down Rationale
Drop Down in Table
From Betts, J., Muntean, W., Kim, D, Kao, S. (Winter 2022). Next Genera-
tion NCLEX ®: Test design. Chicago, NCSBN; National Council of State
Boards of Nursing. (2022). Next Generation NCLEX News. Retrieved
from NGN_Winter22_English_Final.pdf (ncsbn.org).
TABLE 1.5 NGN Scoring Methods
Method Description
Plus-Minus
(+/-) Scoring
One point is given for each correct response.
One point is subtracted for each incorrect re-
sponse.
No negative scores; if the sum is negative, a zero
is assigned.
Used when the test-taker can select any number
of options, such as a highlight in text, highlight
in table, multiple response (select all that apply),
multiple response grouping, or a matrix multiple
response
Zero-One-
(0/1) Scoring
One point is given for each correct response.
Zero points given for incorrect responses.
Points are NOT subtracted for incorrect responses.
Used for items such as drag and drop cloze, drop
down cloze, drop down-in-table, matrix multiple
choice, multiple response select N or bow-tie
Rationale
Scoring
One point is given for each correct grouping of re-
sponse elements; both parts of the paired informa-
tion must be correct to earn a point. Used when
elements of a response are linked, such as drop
down rationale or drag and drop rationale items
From National Council of State Boards of Nursing. (2021). Next Genera-
tion NCLEX News. Retrieved from https://www.ncsbn.org/NGN_Sum
mer21_Eng.pdf; National Council of State Boards of Nursing. (2021).
Braving new pathways: Leading the way for regulatory transformation, 2021
NCSBN annual meeting.
A prescription reads: acetaminophen liquid, 650 mg orally
every 4 hours PRN for pain. The medication label reads: 500
mg/15 mL. The nurse prepares how many milliliters to admin-
ister one dose? Fill in the blank. Record your answer using one
decimal place.
Answer: 19.5 mL
Formula: Desired
Available × Volume = mL
650
500 15 = 19.5
mg
mg mL mL×
In this question, you need to focus on the subject, mL
per dose, and use the formula for calculating a medication
dose. When the dose is determined, you will need to type your
numeric answer in the answer box. Always follow the specic
directions noted on the computer screen. Also, remember
that there will be an on-screen calculator on the computer for
your use.
BOX 1.7 Fill-in-the-Blank Question
In addition, you must type in a decimal point if neces-
sary. See Box 1.7 for an example.
Multiple-Response Question
For a multiple-response question, also known as a
“select all that apply (SATA)” question, you will be asked
CHAPTER 1 Clinical Judgment and the Next Generation NCLEX (NGN)-RN ® Examination 9
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 proce-
dure?”
2. “Your fears are a sign that you really should have this
procedure.”
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 proce-
dure for the cardiologist.”
Answer: 1
This question addresses the subcategory Caring in the cat-
egory of Integrated Processes. It also addresses the concept
of communication. The correct option utilizes a therapeutic
communication technique that explores the client’s feelings,
determines the level of client understanding about the proce-
dure, 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 reassur-
ance, and puts the client’s feelings on hold. Option 4 dimin-
ishes the client’s feelings by directing attention away from the
client and toward the cardiologist’s importance.
BOX 1.6 Integrated Processes
TABLE 1.4 NGN Item Types
Type of
Item/Case
Scenario Description Item Types
Stand-alone
Item
A stand-alone item
will include a short
scenario about a client
and will be accompa-
nied by one question
that tests more than
one cognitive skill.
Bow-tie
Trend
Unfolding
Case
An unfolding case
study will include
phases as the story
about the client un-
folds and changes.
This will be accom-
panied by six NGN
item type questions,
and each of the six
cognitive skills will be
tested.
Highlight in Text
Highlight in Table
Matrix Multiple Choice
Matrix Multiple Response
Multiple Response Select
N
Multiple Response Select
All That Apply
Multiple Response Group-
ing
Drag and Drop Cloze
Drag and Drop Rationale
Drop Down Cloze
Drop Down Rationale
Drop Down in Table
From Betts, J., Muntean, W., Kim, D, Kao, S. (Winter 2022). Next Genera-
tion NCLEX ®: Test design. Chicago, NCSBN; National Council of State
Boards of Nursing. (2022). Next Generation NCLEX News. Retrieved
from NGN_Winter22_English_Final.pdf (ncsbn.org).
TABLE 1.5 NGN Scoring Methods
Method Description
Plus-Minus
(+/-) Scoring
One point is given for each correct response.
One point is subtracted for each incorrect re-
sponse.
No negative scores; if the sum is negative, a zero
is assigned.
Used when the test-taker can select any number
of options, such as a highlight in text, highlight
in table, multiple response (select all that apply),
multiple response grouping, or a matrix multiple
response
Zero-One-
(0/1) Scoring
One point is given for each correct response.
Zero points given for incorrect responses.
Points are NOT subtracted for incorrect responses.
Used for items such as drag and drop cloze, drop
down cloze, drop down-in-table, matrix multiple
choice, multiple response select N or bow-tie
Rationale
Scoring
One point is given for each correct grouping of re-
sponse elements; both parts of the paired informa-
tion must be correct to earn a point. Used when
elements of a response are linked, such as drop
down rationale or drag and drop rationale items
From National Council of State Boards of Nursing. (2021). Next Genera-
tion NCLEX News. Retrieved from https://www.ncsbn.org/NGN_Sum
mer21_Eng.pdf; National Council of State Boards of Nursing. (2021).
Braving new pathways: Leading the way for regulatory transformation, 2021
NCSBN annual meeting.
A prescription reads: acetaminophen liquid, 650 mg orally
every 4 hours PRN for pain. The medication label reads: 500
mg/15 mL. The nurse prepares how many milliliters to admin-
ister one dose? Fill in the blank. Record your answer using one
decimal place.
Answer: 19.5 mL
Formula: Desired
Available × Volume = mL
650
500 15 = 19.5
mg
mg mL mL×
In this question, you need to focus on the subject, mL
per dose, and use the formula for calculating a medication
dose. When the dose is determined, you will need to type your
numeric answer in the answer box. Always follow the specic
directions noted on the computer screen. Also, remember
that there will be an on-screen calculator on the computer for
your use.
BOX 1.7 Fill-in-the-Blank Question
In addition, you must type in a decimal point if neces-
sary. See Box 1.7 for an example.
Multiple-Response Question
For a multiple-response question, also known as a
“select all that apply (SATA)” question, you will be asked
Loading page 28...
Preparation
UNIT I NCLEX-RN ® Exam Preparation
to select or check all of the options, such as nursing
interventions, that relate to the information in the ques-
tion. In these question types, there may be one correct
answer, there may be more than one correct answer, or
all answers could be correct. See Box 1.8 for an example.
Ordered-Response Question
In this type of question, you will be asked to place nurs-
ing actions in order of priority. Information will be pre-
sented in a question and, based on the data, you need
to determine what you will do rst, second, third, and
so forth. Specic directions for answering are provided
with the question. See Figure 1.1 for an example.
Figure or Hot Spot Question
A question with a picture or graphic will ask you to
answer the question based on the picture or graphic.
The question could contain a chart, a table, or a gure or
illustration. You also may be asked to use the computer
mouse to point and click on a specic area (hot spot)
in the visual. A chart, table, gure, or illustration may
appear in any type of question, including a multiple-
choice question. See Box 1.10 for an example.
Chart/Exhibit Question
In this type of question, you will be presented with a
client situation and a chart, medical record, or exhibit.
You will be provided with tabs or buttons that you need
to click to obtain the information needed to answer the
question. A prompt or message will appear that will indi-
cate the need to click on a tab or button. See Box 1.9 for
an example.
Graphic Item Option Question
In this type of question, the option selections will be
pictures rather than text. You will select the option
that represents your answer choice. See Box 1.11 for an
example.
Audio Questions
Audio questions will require listening to a sound to
answer the question. These questions will prompt you to
use the headset provided and to click on the sound icon.
You will be able to click on the volume button to adjust
the volume to your comfort level, and you will be able
to listen to the sound as many times as necessary. Con-
tent examples include, but are not limited to, various
lung sounds, heart sounds, or bowel sounds. Examples
of this question type are located on the accompanying
Evolve site See Figure 1.2 for an example..
The NCSBN provides a practice test for candidates
that is composed of previously used NCLEX questions
that are no longer a part of the NCLEX. This exam simu-
lates the look of the real exam and provides the candi-
date with practice for the NCLEX. This practice test can
be purchased through the NCSBN at www.ncsbn.org
Registering to Take the Examination
It is important to obtain an NCLEX Examination
Candidate Bulletin from the NCSBN website at
www.ncsbn.org, because this bulletin provides all of the
information you need to register for and schedule your
examination. It also provides you with website and tele-
phone information for NCLEX examination contacts.
The initial step in the registration process is to submit
an application to the state board of nursing in the state
in which you intend to obtain licensure. You need to
obtain information from the board of nursing regarding
The emergency department nurse is caring for a child suspected of acute epiglottitis. Which interventions apply in the care of the
child? Select all that apply.
1. Obtain a throat culture.
2. Auscultate lung sounds.
3. Maintain the child in a supine position.
4. Obtain a pediatric-size tracheostomy tray.
5. Place the child on an oxygen saturation monitor.
6. Prepare the child for a lateral neck and chest x-ray.
In a multiple-response question, you will be asked to select or check all of the options, such as interventions, that relate to the
information in the question. Focus on the subject, interventions for the child with suspected acute epiglottitis. To answer this question,
recall that acute epiglottitis is a serious obstructive inammatory process that requires immediate intervention and that airway patency
is a priority. Auscultating lung sounds allows the nurse to obtain information about airway patency without causing further airway
compromise, which can happen by examining the throat. Examination of the throat with a tongue depressor or attempting to obtain a
throat culture is contraindicated because the examination can precipitate further obstruction. A lateral neck and chest x-ray is obtained
to determine the degree of obstruction, if present. To reduce respiratory distress, the child should sit upright. The child is placed on
an oxygen saturation monitor to monitor oxygenation status. Tracheostomy and intubation may be necessary if respiratory distress is
severe. Remember to follow the specic directions given on the computer screen.
BOX 1.8 Multiple-Response Question
UNIT I NCLEX-RN ® Exam Preparation
to select or check all of the options, such as nursing
interventions, that relate to the information in the ques-
tion. In these question types, there may be one correct
answer, there may be more than one correct answer, or
all answers could be correct. See Box 1.8 for an example.
Ordered-Response Question
In this type of question, you will be asked to place nurs-
ing actions in order of priority. Information will be pre-
sented in a question and, based on the data, you need
to determine what you will do rst, second, third, and
so forth. Specic directions for answering are provided
with the question. See Figure 1.1 for an example.
Figure or Hot Spot Question
A question with a picture or graphic will ask you to
answer the question based on the picture or graphic.
The question could contain a chart, a table, or a gure or
illustration. You also may be asked to use the computer
mouse to point and click on a specic area (hot spot)
in the visual. A chart, table, gure, or illustration may
appear in any type of question, including a multiple-
choice question. See Box 1.10 for an example.
Chart/Exhibit Question
In this type of question, you will be presented with a
client situation and a chart, medical record, or exhibit.
You will be provided with tabs or buttons that you need
to click to obtain the information needed to answer the
question. A prompt or message will appear that will indi-
cate the need to click on a tab or button. See Box 1.9 for
an example.
Graphic Item Option Question
In this type of question, the option selections will be
pictures rather than text. You will select the option
that represents your answer choice. See Box 1.11 for an
example.
Audio Questions
Audio questions will require listening to a sound to
answer the question. These questions will prompt you to
use the headset provided and to click on the sound icon.
You will be able to click on the volume button to adjust
the volume to your comfort level, and you will be able
to listen to the sound as many times as necessary. Con-
tent examples include, but are not limited to, various
lung sounds, heart sounds, or bowel sounds. Examples
of this question type are located on the accompanying
Evolve site See Figure 1.2 for an example..
The NCSBN provides a practice test for candidates
that is composed of previously used NCLEX questions
that are no longer a part of the NCLEX. This exam simu-
lates the look of the real exam and provides the candi-
date with practice for the NCLEX. This practice test can
be purchased through the NCSBN at www.ncsbn.org
Registering to Take the Examination
It is important to obtain an NCLEX Examination
Candidate Bulletin from the NCSBN website at
www.ncsbn.org, because this bulletin provides all of the
information you need to register for and schedule your
examination. It also provides you with website and tele-
phone information for NCLEX examination contacts.
The initial step in the registration process is to submit
an application to the state board of nursing in the state
in which you intend to obtain licensure. You need to
obtain information from the board of nursing regarding
The emergency department nurse is caring for a child suspected of acute epiglottitis. Which interventions apply in the care of the
child? Select all that apply.
1. Obtain a throat culture.
2. Auscultate lung sounds.
3. Maintain the child in a supine position.
4. Obtain a pediatric-size tracheostomy tray.
5. Place the child on an oxygen saturation monitor.
6. Prepare the child for a lateral neck and chest x-ray.
In a multiple-response question, you will be asked to select or check all of the options, such as interventions, that relate to the
information in the question. Focus on the subject, interventions for the child with suspected acute epiglottitis. To answer this question,
recall that acute epiglottitis is a serious obstructive inammatory process that requires immediate intervention and that airway patency
is a priority. Auscultating lung sounds allows the nurse to obtain information about airway patency without causing further airway
compromise, which can happen by examining the throat. Examination of the throat with a tongue depressor or attempting to obtain a
throat culture is contraindicated because the examination can precipitate further obstruction. A lateral neck and chest x-ray is obtained
to determine the degree of obstruction, if present. To reduce respiratory distress, the child should sit upright. The child is placed on
an oxygen saturation monitor to monitor oxygenation status. Tracheostomy and intubation may be necessary if respiratory distress is
severe. Remember to follow the specic directions given on the computer screen.
BOX 1.8 Multiple-Response Question
Loading page 29...
Preparation
CHAPTER 1 Clinical Judgment and the Next Generation NCLEX (NGN)-RN ® Examination 11
FIG. 1.1 Example of an ordered-response question.
the specic registration process, because the process may
vary from state to state. Then, use the NCLEX Examina-
tion Candidate Bulletin as your guide to complete the
registration process.
Following the registration instructions and com-
pleting the registration forms precisely and accurately
are important. Registration forms not properly com-
pleted or not accompanied by the proper fees in the
required method of payment will be returned to you
and will delay testing. You must pay a fee for taking
the examination; you also may have to pay additional
fees to the board of nursing in the state in which you
are applying.
Authorization to Test Form and
Scheduling an Appointment
Once you are eligible to test, you will receive an Authori-
zation to Test (ATT) form. You cannot make an appoint-
ment until you receive an ATT form. Note the validity
dates on the ATT form, and schedule a testing date and
time before the expiration date on the ATT form. The
NCLEX Examination Candidate Bulletin provides you
with the directions for scheduling an appointment; you
do not have to take the examination in the same state in
which you are seeking licensure.
The ATT form contains important information,
including your test authorization number, candidate
identication number, and validity date. You need to
take your ATT form to the testing center on the day
of your examination. You will not be admitted to the
examination if you do not have it.
Changing Your Appointment
If for any reason you need to change your appointment
to test, you can make the change on the candidate web-
site or by calling candidate services. Refer to the NCLEX
Examination Candidate Bulletin for this contact infor-
mation and other important procedures for canceling
and changing an appointment. If you fail to arrive for
the examination or fail to cancel your appointment
to test without providing appropriate notice, you will
forfeit your examination fee and your ATT form will be
invalidated. This information will be reported to the
board of nursing in the state in which you have applied
for licensure, and you will be required to register and
pay the testing fees again.
CHAPTER 1 Clinical Judgment and the Next Generation NCLEX (NGN)-RN ® Examination 11
FIG. 1.1 Example of an ordered-response question.
the specic registration process, because the process may
vary from state to state. Then, use the NCLEX Examina-
tion Candidate Bulletin as your guide to complete the
registration process.
Following the registration instructions and com-
pleting the registration forms precisely and accurately
are important. Registration forms not properly com-
pleted or not accompanied by the proper fees in the
required method of payment will be returned to you
and will delay testing. You must pay a fee for taking
the examination; you also may have to pay additional
fees to the board of nursing in the state in which you
are applying.
Authorization to Test Form and
Scheduling an Appointment
Once you are eligible to test, you will receive an Authori-
zation to Test (ATT) form. You cannot make an appoint-
ment until you receive an ATT form. Note the validity
dates on the ATT form, and schedule a testing date and
time before the expiration date on the ATT form. The
NCLEX Examination Candidate Bulletin provides you
with the directions for scheduling an appointment; you
do not have to take the examination in the same state in
which you are seeking licensure.
The ATT form contains important information,
including your test authorization number, candidate
identication number, and validity date. You need to
take your ATT form to the testing center on the day
of your examination. You will not be admitted to the
examination if you do not have it.
Changing Your Appointment
If for any reason you need to change your appointment
to test, you can make the change on the candidate web-
site or by calling candidate services. Refer to the NCLEX
Examination Candidate Bulletin for this contact infor-
mation and other important procedures for canceling
and changing an appointment. If you fail to arrive for
the examination or fail to cancel your appointment
to test without providing appropriate notice, you will
forfeit your examination fee and your ATT form will be
invalidated. This information will be reported to the
board of nursing in the state in which you have applied
for licensure, and you will be required to register and
pay the testing fees again.
Loading page 30...
Preparation
UNIT I NCLEX-RN ® Exam Preparation12
BOX 1.9 Chart/Exhibit Question
A 30-year-old client visits the clinic and requests a prescription
for oral contraceptives. The nurse performs an assessment on
the client and reviews the history and physical examination
documented in the medical record from the client’s previous
visit. The nurse determines that oral contraceptives are contra-
indicated because of which documented items? Refer to chart.
Select all that apply.
Client’s Chart
History and
Physical
Medications Diagnostic Results
Past medical his-
tory:
Deep vein throm-
bosis with asso-
ciated thrombo-
phlebitis
Hypertension
Coronary artery
disease
Prediabetes
Multivitamin
1 orally daily
Lisinopril 40
mg orally
daily
Atorvastatin
10 mg orally
daily
Metformin
500 mg
orally twice
daily
Renal ultrasound
shows no hydrone-
phrosis, no renal
artery stenosis
Complete blood cell
count shows white
blood cells (WBC)
5,000 mm3 (5 ×
9 /L), hemoglobin
(Hgb) 16 g/dL
(60 g/L), hematocrit
(Hct) 47% (0.47),
platelets 590,000
mm3 (590 × 109 /L)
1. Hypertension
2. Prediabetes
3. Coronary artery disease
4. Renal ultrasound results
5. Takes multivitamin orally daily
6. Takes lisinopril 40 mg orally daily
7. Takes atorvastatin 10 mg orally daily
8. Complete blood cell count results
9. Takes metformin 500 mg orally twice daily
10. Past medical history of deep vein thrombosis with
associated thrombophlebitis
Answer: 1, 3, 8, 10
This chart/exhibit question provides you with data from the
client’s medical record. Focus on the subject, the item(s) that
are a contraindication to the use of oral contraceptives. Oral
contraceptives are contraindicated in women with a history of
any of the following: thrombophlebitis and thromboembolic
disorders, cardiovascular or cerebrovascular diseases (includ-
ing stroke), any estrogen-dependent cancer or breast cancer,
benign or malignant liver tumors, impaired liver function, hyper-
tension, and diabetes mellitus with vascular involvement. This
client has prediabetes, which is not a contraindication. Items 1
and 3 are cardiovascular diseases. The client has hypertension,
coronary artery disease, and deep vein thrombosis with associ-
ated thrombophlebitis, all contraindications to the use of oral
contraceptives. The renal ultrasound result is not signicant.
The medications the client is taking are not specic contraindi-
cations to oral contraceptives. The normal WBC is 5000-10,000
mm3 (5-10 × 9 /L). The normal Hgb ranges from 12-18 g/dL
(120-180 g/L). The normal Hct ranges from 37-52% (0.37-0.52).
The normal platelet count is 150,000-400,000 mm3 (150-400 ×
9 /L). Item 8 has components that indicate a contraindication;
of note is that the platelet count is elevated and thus this cli-
ent has polycythemia, which is a thromboembolic disorder and
therefore a contraindication for the use of oral contraceptives.
Option 10 notes that the client has a history of deep vein throm-
bosis with associated thrombophlebitis, a contraindication to
the use of oral contraceptives.
BOX 1.10 Figure Question
A client who experienced a myocardial infarction is being monitored via cardiac telemetry. The nurse notes the sudden onset of this
cardiac rhythm on the monitor (refer to figure) and immediately takes which action?
1. Takes the client’s blood pressure
2. Initiates cardiopulmonary resuscitation (CPR)
3. Places a nitroglycerin tablet under the client’s tongue
4. Continues to monitor the client and then contacts the
cardiologist
Answer: 2
This question requires you to identify the cardiac rhythm and
then determine the priority nursing action. Note the strategic
word, immediately. This cardiac rhythm identies a coarse ven-
tricular brillation (VF). The goals of treatment are to termi-
nate VF promptly and to convert it to an organized rhythm. The
physician, cardiologist, or an Advanced Cardiac Life Support
(ACLS)–qualied nurse must immediately debrillate the client.
If a debrillator is not readily available, CPR is initiated until the
debrillator arrives. Options 1, 3, and 4 are incorrect actions
and delay lifesaving treatment.
UNIT I NCLEX-RN ® Exam Preparation12
BOX 1.9 Chart/Exhibit Question
A 30-year-old client visits the clinic and requests a prescription
for oral contraceptives. The nurse performs an assessment on
the client and reviews the history and physical examination
documented in the medical record from the client’s previous
visit. The nurse determines that oral contraceptives are contra-
indicated because of which documented items? Refer to chart.
Select all that apply.
Client’s Chart
History and
Physical
Medications Diagnostic Results
Past medical his-
tory:
Deep vein throm-
bosis with asso-
ciated thrombo-
phlebitis
Hypertension
Coronary artery
disease
Prediabetes
Multivitamin
1 orally daily
Lisinopril 40
mg orally
daily
Atorvastatin
10 mg orally
daily
Metformin
500 mg
orally twice
daily
Renal ultrasound
shows no hydrone-
phrosis, no renal
artery stenosis
Complete blood cell
count shows white
blood cells (WBC)
5,000 mm3 (5 ×
9 /L), hemoglobin
(Hgb) 16 g/dL
(60 g/L), hematocrit
(Hct) 47% (0.47),
platelets 590,000
mm3 (590 × 109 /L)
1. Hypertension
2. Prediabetes
3. Coronary artery disease
4. Renal ultrasound results
5. Takes multivitamin orally daily
6. Takes lisinopril 40 mg orally daily
7. Takes atorvastatin 10 mg orally daily
8. Complete blood cell count results
9. Takes metformin 500 mg orally twice daily
10. Past medical history of deep vein thrombosis with
associated thrombophlebitis
Answer: 1, 3, 8, 10
This chart/exhibit question provides you with data from the
client’s medical record. Focus on the subject, the item(s) that
are a contraindication to the use of oral contraceptives. Oral
contraceptives are contraindicated in women with a history of
any of the following: thrombophlebitis and thromboembolic
disorders, cardiovascular or cerebrovascular diseases (includ-
ing stroke), any estrogen-dependent cancer or breast cancer,
benign or malignant liver tumors, impaired liver function, hyper-
tension, and diabetes mellitus with vascular involvement. This
client has prediabetes, which is not a contraindication. Items 1
and 3 are cardiovascular diseases. The client has hypertension,
coronary artery disease, and deep vein thrombosis with associ-
ated thrombophlebitis, all contraindications to the use of oral
contraceptives. The renal ultrasound result is not signicant.
The medications the client is taking are not specic contraindi-
cations to oral contraceptives. The normal WBC is 5000-10,000
mm3 (5-10 × 9 /L). The normal Hgb ranges from 12-18 g/dL
(120-180 g/L). The normal Hct ranges from 37-52% (0.37-0.52).
The normal platelet count is 150,000-400,000 mm3 (150-400 ×
9 /L). Item 8 has components that indicate a contraindication;
of note is that the platelet count is elevated and thus this cli-
ent has polycythemia, which is a thromboembolic disorder and
therefore a contraindication for the use of oral contraceptives.
Option 10 notes that the client has a history of deep vein throm-
bosis with associated thrombophlebitis, a contraindication to
the use of oral contraceptives.
BOX 1.10 Figure Question
A client who experienced a myocardial infarction is being monitored via cardiac telemetry. The nurse notes the sudden onset of this
cardiac rhythm on the monitor (refer to figure) and immediately takes which action?
1. Takes the client’s blood pressure
2. Initiates cardiopulmonary resuscitation (CPR)
3. Places a nitroglycerin tablet under the client’s tongue
4. Continues to monitor the client and then contacts the
cardiologist
Answer: 2
This question requires you to identify the cardiac rhythm and
then determine the priority nursing action. Note the strategic
word, immediately. This cardiac rhythm identies a coarse ven-
tricular brillation (VF). The goals of treatment are to termi-
nate VF promptly and to convert it to an organized rhythm. The
physician, cardiologist, or an Advanced Cardiac Life Support
(ACLS)–qualied nurse must immediately debrillate the client.
If a debrillator is not readily available, CPR is initiated until the
debrillator arrives. Options 1, 3, and 4 are incorrect actions
and delay lifesaving treatment.
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Subject
National Council Licensure Examination