

If you can systematically eliminate false answers, you can reduce a four-answer question to a two-answer one and thereby make your chances as good as those in the true-false type of question; that is, odds will favor your guessing half of the answers correctly.
We think that the following pointers will assist you to narrow down your choices systematically and intelligently.
Always, all, everyone, never, none, must. Answers that include global words such as these should be viewed with caution because they imply that there are no exceptions. There are very few instances in which a correct answer is that absolute. Any suggested answer, such as in the following:
Nurses should exercise caution in interviewing alcoholics because: Alcoholics always exaggerate. Alcoholics are never consistent.
should be looked at with care because any exception will make that a false response. A more reasonable answer to the preceding might be "Alcoholics may not be reliable historians."
Broadest, most comprehensive answers. Choose the answer that includes all the others, which is referred to here as the "umbrella effect." For example, in answering the question:
A main nursing function in group therapy is to:
Help patients give and receive feedback in the group. Encourage patients to bring up their concerns. Facilitate group interaction among the members. Remind patients to address their comments to the group.
Number 3 is the best choice because all the other choices fall under it.
Test how reasonable the answer is by posing a specific situation to yourself. For example, the question might read, "The best approach when interviewing children who have irrational fears is to: (1) Help them analyze why they feel this way." Ask yourself if it is reasonable to use Freudian analysis with 2-year-old children.
Focus on the patient. Usually the reason for doing something with a patient is not to preserve the good reputation of the doctor, hospital, or nurse or to enforce rules. Wrong choices would focus on enlisting the patient's cooperation for the purpose of fulfilling orders or because it is the rule. On seeing a patient out of bed against orders, instead of just saying, "It's against doctor's orders for you to get up," you might better respond by focusing on how the patient is reacting to the restriction on his mobility, by saying, for example, "I can see that you want to get up and that it is upsetting to you to be in bed now. Let me help you get back to bed safely and see what I can do for you."
Eliminate any answer that takes for granted that anyone is unworthy or ignorant. For example, in the question, "The patient should not be told the full extent of her condition because . . .," a poor response would be, ". . . she would not understand." Choose an answer that focuses on the patient as a worthy human being
When you do not know the best answer, and need to guess, look for the answer that may be different from the others. For example, if all choices but one are stated in milligrams and the exception reads "1 g," that choice may be a distractor or the best choice.
Read the question carefully to see if a negative modifier is used. If the question asks, "Which of the following is least helpful," be sure to gear your thinking accordingly. Emphasize a key word such as least as you read the questions.
Do not look for a pattern in the correct answers. If you have already selected option 3 for several questions in a row, do not be reluctant to choose option 3 again, if you think that it is the correct response.
Look for the choices that you know* are either correct or may be incorrect.* You can save time and narrow your selection by using this strategy.
In eliminating potentially wrong psychosocial answers, remember to look for examples of what has been included in the nontherapeutic response list.
Wrong choices tend to be either very brief or very long and involved.
12. Better psychosocial nursing responses to select are those responses that (a) focus on feelings (unless safety is at stake!): "How did that make you feel?" (b) reflect the patient's comments: "You say that made you angry"; (c) communicate acceptance of the patient by the nurse rather than criticism or a value judgment; (d) acknowledge the patient: "I see that you are wincing"; and (e) stay in the here-and-now: "What will help now?" Examples of better choices can be found in the therapeutic responses list.
Look for the average, acceptable, safe, common, typical, "garden variety" responses, not the "exception to the rule," esoteric, or controversial responses.
Eliminate the response that may be the best for a physician to make. Look for an RN role-appropriate psychosocial response; for example, psychiatrists analyze the past, and nurses in general focus on present feelings and situations.
Look for similarities and groupings in responses and the one-of-a-kind key idea in multiple choice responses. Example: At which activity would it be important to protect the patient who is on phenothiazines from the side effects of this drug? 1. Sunday church services. 2. A twilight concert 3. A midday movie in the theater. 4. A luncheon picnic on the hospital grounds. Choices 1,2, and 3 all involve indoor activities. Choice 4 involves outdoor exposure during the height of the sun's rays. Patients need to be protected against photosensitivity and burns when on phenothiazines.
Be sure to note whether the question asks for what is the first or initial response to be made or action to be taken by the nurse. The choices listed may all be correct, but in this situation selecting the response with the highest priority is important. If the question asks for an immediate action, probably all answers are correct and you need to choose the priority answer.
When you do not know the specific facts called for in a question, use your skills of reasoning; for example, when an answer involves amounts or time (mainly numbers) and you do not know the answer and cannot find any basis for reasoning (all else being equal), avoid the extreme responses (the highest or lowest numerical values).
Give special attention to questions in which each word counts. The purpose of this type of question may be not only to test your knowledge but also to see if you can read accurately and find the main point. In such questions, each answer may be a profusion of words, but there may be one or two words that make the critical difference. If the option has several aspects, all the parts must be correct for that answer to be correct. If you can eliminate one aspect in an answer, you can eliminate the other options with that aspect.
All else being equal, select the response that you best understand. Long-winded statements are likely to be included as distractors and may be a lot of words signifying little or nothing, such as "criteria involved in implementing conceptual referents for standardizing protocol." You may want to eliminate unusual or highly technical language. Relate the situation to something that is familiar to you.
Apply skim-reading techniques. Read the practice questions in this book quickly. Pick out key words (write them down, if that is helpful to you). Translate, into your own words, the gist of what is asked in the question. You might close your eyes at this point and see if the answer "pops" into mind. Then, skim the answer choices, looking for the response that corresponds to what first came into your mind. Key ideas or themes to look for in psychosocial responses have been covered in this section— look for a "feeling" response, acceptance, acknowledgment of the patient, and reflection, for example.
Look for the best answer; not the right answer; for example, incorrect action may be the best answer if the stem asks for an action that is not appropriate (e.g., "Which of the following is an inappropriate action?" can be rephrased to say "Which action is wrong?").
To narrow down the choices, first find two contradictory options; for example, hypo—hyper, flex—extend, give—withhold, dilate—constrict; then focus on which one may be the correct or best choice.
Focus on the age-appropriate answer (e.g., "When caring for a toddler, with what safety issue should the nurse be concerned?").
Time sequence points to the best choice; e.g., ask yourself when is this taking place (e.g., prenatal or postpartum; preoperative or postoperative; before, during, or after; early or late; immediately?).
In medication administration questions, apply the 5 rights: Right Medication, Right Route, Right Patient, Right Dosage, Right Time
When more than one answer looks right, choose the first step of the nursing process (assess before "implement"). Assessment words and phrases indicate priority: Ascertain Assess Check Collect Detect Determine Find out Identify Look Monitor Observe Obtain information Recognize
Isolate the verbs from the rest of the question (e.g., ask is better than tell, give, or ignore).
Do not overlook the obvious answer: KIS (Keep It Simple); for example, the best answer for what to do when there is a malodor in the room of a patient with a colostomy is to "check the stoma for fecal leakage." If it smells like feces, check for feces.
As you read what is given for assessment findings (e.g., signs and symptoms) ask yourself: Is this OK? Or is it not OK?
When two options are correct, choose the one that covers them both (i.e., incorporates the other, like a telescope). Example: Two hours after a liver biopsy, the nurse finds the patient lying on the left side. What is the best nursing action at this time? 1. Check for bleeding. 2. Turn the patient onto the right side. Both options are correct, but choose option 2 because it incorporates option 1; it is possible to check for bleeding while turning the patient over onto the right side (where the liver is), to put pressure on the site (as a preventive measure when postbiopsy bleeding is possible).
Look at root words to give you a clue: for example, hemi = one half (hemianopsia = "half without vision"). Break down unfamiliar words in the stem.
Remember Maslow—"soma before psyche"—physiological needs are before psychosocial (i.e., physical needs first). Use Maslow's hierarchy to establish priorities when more than one answer looks correct. Example: What is the priority nursing care for a patient after ECT? 1. Reorient to time and place. 2. Put the side rails up. 3. Explain that memory loss is an expected outcome. When all three options are good (as in this case), select the physical aspect of care first (option 2) rather than either of the two psychosocial options.
Think safety as the best choice when more than one answer could be right. Safety is a priority. See the preceding example, where putting side rails up is a "safety" action.
Visualize the condition, behavior, situation, and the options to help you choose the best answer. Form a mental image (e.g., what flexion looks like versus extension); visualize and sound out the answers (e.g., to eliminate trite clichés or "authoritarian"-sounding responses such as "That's not allowed here").
"Would that you could that the ideal be possible." Choose an answer for the "ideal," not real, world. Do not use real world experiences to answer NCLEX questions (i.e., on the exam, answer as if you have all the time, all the staff, and all the equipment).
When in doubt as to which answer is best, use the process of elimination first (e.g., eliminate what you know is in correct) to narrow your choice to two options. The best choice will provide an answer to what the question is asking.
Apply the ABCS when the question calls for priorities: Airway Breathing Circulation Safety
An important goal is to maximize patient actions. For example, choose options that have indicator words for "encourage": Reinforce Support Facilitate Assist Help Aid Foster
Try to turn options into true-or-false responses if possible in order to narrow down to two possible options; for example, when a question asks about adjusting insulin dosage, ask yourself, "What is true about adjusting the dose?" "Is it true or false that dosage is increased when the patient has an infection?" (True.) "Is it true or false that dosage is decreased when blood glucose level increases?" (False.) If you find no "true" answers, look at the choices for a "maybe" answer.
Use acronyms and memory aids to help remember theory in selecting an answer (see Appendix N). SWISS—management of Cushing's: Sugar (hyperglycemia) Water (fluid retention) Infection (prone to ...) Sodium (retention) Sex changes (no menses) 5 P's of fracture: Pain Pallor Pulselessness Paresthesia Paralysis WOUND healing—affected by: Wound dimensions Overweight Undiagnosed infections Nutritional deficiencies Diabetes, Disabilities (e.g., immunosuppressed)
Reword the question if the stem says "further teaching is necessary" (e.g., the best answer will have an incorrect statement).
Recognize what is normal, for example, the data presented is normal. Or is the sign/symptom presented an "Oh! Oh!" (meaning that a problem exists)?
Do not delegate functions of assessment, evaluation, and nursing judgment to an LVN/LPN or CNA (Certified Nursing Assistant) (e.g., do not delegate admitting a patient from the OR to the unit, nor establish a plan of care, nor teach or give telephone advice; do not handle invasive lines).
Do delegate activities to LVN/LPN or CNA for stable patients with predictable outcomes (e.g., help ambulate a patient who is 2 days postsurgery). Do delegate to LVN/LPN or CNA activities that involve standard, unchanging procedures (e.g., take vital signs after ambulation, do clean catheterizations, simple dressing changes, suction chronic tracheostomies using clean technique).
In positioning a patient, decide what you are trying to prevent (e.g., contractures) or promote (e.g., venous return).
To help decide in which position to place a patient, form a mental image of each position in the options (e.g., picture supine, high Fowler, semi-Fowler, Sims, prone, Trendelenburg, lithotomy, dorsal recumbent).
When none of the options looks good, identify the nursing concept implied in the options given (e.g., risk factors for infection).
When in doubt, reread answer choices to obtain clues, rather than rereading the question. When you come across a question that is about unfamiliar nursing content (e.g., paracentesis), ask yourself, "What is the topic of the question?" "What do the answer choices mean?" Then reword the question using the clues from the options. Example: What is most important for the nurse to ask a patient immediately after a paracentesis? 1. "Are you in pain?" 2. "Do you feel dizzy?" 3. "Does your underwear fit better around the belt line?" 4. "Do you need to urinate?" Based on rereading the options, you can reword the question to, "What is an untoward reaction (complication) after this procedure?" The answer choices relate to expected outcomes (1, 3), a question that is not relevant to ask after the procedure (4), and a complication (2), which is the correct option.
Recognize expected outcomes of drugs and treatments/ procedures. Example: What will indicate improvement in the condition of the patient who has anorexia nervosa? 1. The patient has gained weight. 2. The patient weighs herself every day. 3. The patient eats all the foods served to her. 4. The patient asks the parents to bring her favorite foods. Choose the option that shows progress toward the goal (in this condition, it is weight gain that is expected).
When you do not know the answer, choose what will cause the least harm. Example: The nurse suspects abdominal wound dehiscence when lifting the edges of the patient's dressings. What should the nurse do next? 1. Tell the patient to remain quiet and not cough. 2. Offer a warm drink to help relax the patient. 3. Place the patient with feet elevated. 4. Change the dressing. Option 1 is the best answer, because it will not add damage that could happen with changing the position or the dressing.
Take care of the patient first, not the equipment or the family (unless a family member is the focus of the question).
If one option has generally, usually, tends to but other options do not have these qualifiers, use the one option that does have the qualifier as the best answer.
Look for a similar word or phrase used in the question and in one of the options. For example, if the question states that the patient is on an intermediate-acting insulin (NPH), and the stem asks for its peak action, look for a middle time—between a choice of: 4 hours after the injection, 6-12,12-14, or 15-18. Choose 6-12 hours (as the midpoint).
If two options say the same thing, neither can be the answer because both are distractors. Example: What might the nurse expect to see when a patient with cirrhosis is hospitalized with ascites? 1. Patient is likely to be anorexic. 2. Patients intake will be poor, especially if served large portions. You can eliminate both of these options because they are saying the same thing in different words: the patient is likely to be uninterested in eating.
Don't "pass the buck"—think what is a nursing action that an RN can do before calling the MD. Example: After surgery, a patient with diabetes complains of nausea, appears lethargic and flushed, with BP 108/78, P 100, R 24 and deep. What is the next action? 1. Call the MD. 2. Check the patients glucose. 3. Give an antiemetic. 4. Change the IV infusion rate. The nurse should assess (option 2) before calling the MD (who may then order an antiemetic, option 3, and alter the IV infusion rate, option 4).
Focus on key words in the sfem of the question as your clue: Best Essential Highest Immediate Least likely Most Most appropriate Most likely Vital
"Action" does not always mean choose an "implementation" type of answer. The question may ask: "What is the best nursing action?" However, the answer may be an "assessment" option. Example: What is the best action for the nurse to take when a mother at the clinic reports that her diabetic child is hyperglycemic in the morning (215 mg/dL), although the child has been well controlled with NPH and regular insulin before breakfast and dinner? 1. Suggest that the mother give the bedtime snack earlier. 2. Suggest that the insulin be given later in the evening. 3. Suggest that they continue with the same regimen. 4. Check the blood sugar now, and suggest that the mother check it during the night. Choose "check," which is an "assessment" response (option 4), although the question (the stem) is phrased as an implementation ("best action" is an implementation).
Remember the nursing hierarchy. Go to the next line of nursing authority (e.g., staff —> charge nurse; LPN/LVN —» staff nurse) when the question asks to whom to report a situation; for example, if the question is about an LVN/LPN, the best answer is to report to the staff nurse.
When the question includes lab values, ask yourself whether the given value is "Oh! Oh!" (meaning too high or too low); or "Eh" (meaning not a particular problem). For example, a serum K+ of 8.5 is "Oh! Oh!" (too high).
Prevention is a key concept (e.g., when the question deals with infection control, and in health teaching). Example: The primary objective in ileostomy teaching with a patient during early postoperative period is to: 1. Facilitate maintenance of intake and output records. 2. Control unpleasant odors. 3. Prevent skin excoriation around the stoma. 4. Reduce the risk of postoperative wound infection. Choose "prevention" (option 3), which in turn may prevent contamination of abdominal incision (option 4). Options 1 and 2 are secondary objectives.

If you can systematically eliminate false answers, you can reduce a four-answer question to a two-answer one and thereby make your chances as good as those in the true-false type of question; that is, odds will favor your guessing half of the answers correctly.

We think that the following pointers will assist you to narrow down your choices systematically and intelligently.

Always, all, everyone, never, none, must. Answers that include global words such as these should be viewed with caution because they imply that there are no exceptions. There are very few instances in which a correct answer is that absolute. Any suggested answer, such as in the following:

Nurses should exercise caution in interviewing alcoholics because:

Alcoholics always exaggerate.
Alcoholics are never consistent.

should be looked at with care because any exception will make that a false response. A more reasonable answer to the preceding might be "Alcoholics may not be reliable historians."

Broadest, most comprehensive answers. Choose the answer that includes all the others, which is referred to here as the "umbrella effect." For example, in answering the question:

A main nursing function in group therapy is to:

Help patients give and receive feedback in the group.

Encourage patients to bring up their concerns.

Facilitate group interaction among the members.

Remind patients to address their comments to the group.

Number 3 is the best choice because all the other choices fall under it.

Test how reasonable the answer is by posing a specific situation to yourself. For example, the question might read, "The best approach when interviewing children who have irrational fears is to: (1) Help them analyze why they feel this way." Ask yourself if it is reasonable to use Freudian analysis with 2-year-old children.

Focus on the patient. Usually the reason for doing something with a patient is not to preserve the good reputation of the doctor, hospital, or nurse or to enforce rules. Wrong choices would focus on enlisting the patient's cooperation for the purpose of fulfilling orders or because it is the rule. On seeing a patient out of bed against orders, instead of just saying, "It's against doctor's orders for you to get up," you might better respond by focusing on how the patient is reacting to the restriction on his mobility, by saying, for example, "I can see that you want to get up and that it is upsetting to you to be in bed now. Let me help you get back to bed safely and see what I can do for you."

Eliminate any answer that takes for granted that anyone is unworthy or ignorant. For example, in the question, "The patient should not be told the full extent of her condition because . . .," a poor response would be, ". . . she would not understand." Choose an answer that focuses on the patient as a worthy human being

When you do not know the best answer, and need to guess, look for the answer that may be different from the others. For example, if all choices but one are stated in milligrams and the exception reads "1 g," that choice may be a distractor or the best choice.

Read the question carefully to see if a negative modifier is used. If the question asks, "Which of the following is least helpful," be sure to gear your thinking accordingly. Emphasize a key word such as least as you read the questions.

Do not look for a pattern in the correct answers. If you have already selected option 3 for several questions in a row, do not be reluctant to choose option 3 again, if you think that it is the correct response.

Look for the choices that you know are either correct or may be incorrect. You can save time and narrow your selection by using this strategy.

In eliminating potentially wrong psychosocial answers, remember to look for examples of what has been included in the nontherapeutic response list.

Wrong choices tend to be either very brief or very long and involved.

12. Better psychosocial nursing responses to select are those responses that (a) focus on feelings (unless safety is at stake!): "How did that make you feel?" (b) reflect the patient's comments: "You say that made you angry"; (c) communicate acceptance of the patient by the nurse rather than criticism or a value judgment; (d) acknowledge the patient: "I see that you are wincing"; and (e) stay in the here-and-now: "What will help now?" Examples of better choices can be found in the therapeutic responses list.

Look for the average, acceptable, safe, common, typical, "garden variety" responses, not the "exception to the rule," esoteric, or controversial responses.

Eliminate the response that may be the best for a physician to make. Look for an RN role-appropriate psychosocial response; for example, psychiatrists analyze the past, and nurses in general focus on present feelings and situations.

Look for similarities and groupings in responses and the one-of-a-kind key idea in multiple choice responses.

Example: At which activity would it be important to protect the patient who is on phenothiazines from the side effects of this drug?
1. Sunday church services.
2. A twilight concert
3. A midday movie in the theater.
4. A luncheon picnic on the hospital grounds.

Choices 1,2, and 3 all involve indoor activities. Choice 4 involves outdoor exposure during the height of the sun's rays. Patients need to be protected against photosensitivity and burns when on phenothiazines.

Be sure to note whether the question asks for what is the first or initial response to be made or action to be taken by the nurse. The choices listed may all be correct, but in this situation selecting the response with the highest priority is important. If the question asks for an immediate action, probably all answers are correct and you need to choose the priority answer.

When you do not know the specific facts called for in a question, use your skills of reasoning; for example, when an answer involves amounts or time (mainly numbers) and you do not know the answer and cannot find any basis for reasoning (all else being equal), avoid the extreme responses (the highest or lowest numerical values).

Give special attention to questions in which each word counts. The purpose of this type of question may be not only to test your knowledge but also to see if you can read accurately and find the main point. In such questions, each answer may be a profusion of words, but there may be one or two words that make the critical difference. If the option has several aspects, all the parts must be correct for that answer to be correct. If you can eliminate one aspect in an answer, you can eliminate the other options with that aspect.

All else being equal, select the response that you best understand. Long-winded statements are likely to be included as distractors and may be a lot of words signifying little or nothing, such as "criteria involved in implementing conceptual referents for standardizing protocol." You may want to eliminate unusual or highly technical language. Relate the situation to something that is familiar to you.

Apply skim-reading techniques. Read the practice questions in this book quickly. Pick out key words (write them down, if that is helpful to you). Translate, into your own words, the gist of what is asked in the question. You might close your eyes at this point and see if the answer "pops" into mind. Then, skim the answer choices, looking for the response that corresponds to what first came into your mind. Key ideas or themes to look for in psychosocial responses have been covered in this section— look for a "feeling" response, acceptance, acknowledgment of the patient, and reflection, for example.

Look for the best answer; not the right answer; for example, incorrect action may be the best answer if the stem asks for an action that is not appropriate (e.g., "Which of the following is an inappropriate action?" can be rephrased to say "Which action is wrong?").

To narrow down the choices, first find two contradictory options; for example, hypo—hyper, flex—extend, give—withhold, dilate—constrict; then focus on which one may be the correct or best choice.

Focus on the age-appropriate answer (e.g., "When caring for a toddler, with what safety issue should the nurse be concerned?").

Time sequence points to the best choice; e.g., ask yourself when is this taking place (e.g., prenatal or postpartum; preoperative or postoperative; before, during, or after; early or late; immediately?).

In medication administration questions, apply the 5 rights:
Right Medication, Right Route, Right Patient, Right Dosage, Right Time

When more than one answer looks right, choose the first step of the nursing process (assess before "implement"). Assessment words and phrases indicate priority:

Ascertain
Assess
Check
Collect
Detect
Determine
Find out
Identify
Look
Monitor
Observe
Obtain information
Recognize

Isolate the verbs from the rest of the question (e.g., ask is better than tell, give, or ignore).

Do not overlook the obvious answer: KIS (Keep It Simple); for example, the best answer for what to do when there is a malodor in the room of a patient with a colostomy is to "check the stoma for fecal leakage." If it smells like feces, check for feces.

As you read what is given for assessment findings (e.g., signs and symptoms) ask yourself: Is this OK? Or is it not OK?

When two options are correct, choose the one that covers them both (i.e., incorporates the other, like a telescope).

Example: Two hours after a liver biopsy, the nurse finds the patient lying on the left side. What is the best nursing action at this time?
1. Check for bleeding.
2. Turn the patient onto the right side.

Both options are correct, but choose option 2 because it incorporates option 1; it is possible to check for bleeding while turning the patient over onto the right side (where the liver is), to put pressure on the site (as a preventive measure when postbiopsy bleeding is possible).

Look at root words to give you a clue: for example, hemi = one half (hemianopsia = "half without vision"). Break down unfamiliar words in the stem.

Remember Maslow—"soma before psyche"—physiological needs are before psychosocial (i.e., physical needs first). Use Maslow's hierarchy to establish priorities when more than one answer looks correct.

Example: What is the priority nursing care for a patient after ECT?
1. Reorient to time and place.
2. Put the side rails up.
3. Explain that memory loss is an expected outcome.

When all three options are good (as in this case), select the physical aspect of care first (option 2) rather than either of the two psychosocial options.

Think safety as the best choice when more than one answer could be right. Safety is a priority. See the preceding example, where putting side rails up is a "safety" action.

Visualize the condition, behavior, situation, and the options to help you choose the best answer. Form a mental image (e.g., what flexion looks like versus extension); visualize and sound out the answers (e.g., to eliminate trite clichés or "authoritarian"-sounding responses such as "That's not allowed here").

"Would that you could that the ideal be possible." Choose an answer for the "ideal," not real, world. Do not use real world experiences to answer NCLEX questions (i.e., on the exam, answer as if you have all the time, all the staff, and all the equipment).

When in doubt as to which answer is best, use the process of elimination first (e.g., eliminate what you know is in correct) to narrow your choice to two options. The best choice will provide an answer to what the question is asking.

Apply the ABCS when the question calls for priorities:

Airway
Breathing
Circulation
Safety

An important goal is to maximize patient actions. For example, choose options that have indicator words for "encourage":

Reinforce
Support
Facilitate
Assist
Help
Aid
Foster

Try to turn options into true-or-false responses if possible in order to narrow down to two possible options; for example, when a question asks about adjusting insulin dosage, ask yourself, "What is true about adjusting the dose?" "Is it true or false that dosage is increased when the patient has an infection?" (True.) "Is it true or false that dosage is decreased when blood glucose level increases?" (False.) If you find no "true" answers, look at the choices for a "maybe" answer.

Use acronyms and memory aids to help remember theory in selecting an answer (see Appendix N).

SWISS—management of Cushing's:
- Sugar (hyperglycemia)
- Water (fluid retention)
- Infection (prone to ...)
- Sodium (retention)
- Sex changes (no menses)
5 P's of fracture:
- Pain
- Pallor
- Pulselessness
- Paresthesia
- Paralysis
WOUND healing—affected by:
- Wound dimensions
- Overweight
- Undiagnosed infections
- Nutritional deficiencies
- Diabetes, Disabilities (e.g., immunosuppressed)

Reword the question if the stem says "further teaching is necessary" (e.g., the best answer will have an incorrect statement).

Recognize what is normal, for example, the data presented is normal. Or is the sign/symptom presented an "Oh! Oh!" (meaning that a problem exists)?

Do not delegate functions of assessment, evaluation, and nursing judgment to an LVN/LPN or CNA (Certified Nursing Assistant) (e.g., do not delegate admitting a patient from the OR to the unit, nor establish a plan of care, nor teach or give telephone advice; do not handle invasive lines).

Do delegate activities to LVN/LPN or CNA for stable patients with predictable outcomes (e.g., help ambulate a patient who is 2 days postsurgery). Do delegate to LVN/LPN or CNA activities that involve standard, unchanging procedures (e.g., take vital signs after ambulation, do clean catheterizations, simple dressing changes, suction chronic tracheostomies using clean technique).

In positioning a patient, decide what you are trying to prevent (e.g., contractures) or promote (e.g., venous return).

To help decide in which position to place a patient, form a mental image of each position in the options (e.g., picture supine, high Fowler, semi-Fowler, Sims, prone, Trendelenburg, lithotomy, dorsal recumbent).

When none of the options looks good, identify the nursing concept implied in the options given (e.g., risk factors for infection).

When in doubt, reread answer choices to obtain clues, rather than rereading the question. When you come across a question that is about unfamiliar nursing content (e.g., paracentesis), ask yourself, "What is the topic of the question?" "What do the answer choices mean?" Then reword the question using the clues from the options.

Example: What is most important for the nurse to ask a patient immediately after a paracentesis?
1. "Are you in pain?"
2. "Do you feel dizzy?"
3. "Does your underwear fit better around the belt line?"
4. "Do you need to urinate?"

Based on rereading the options, you can reword the question to, "What is an untoward reaction (complication) after this procedure?" The answer choices relate to expected outcomes (1, 3), a question that is not relevant to ask after the procedure (4), and a complication (2), which is the correct option.

Recognize expected outcomes of drugs and treatments/ procedures.

Example: What will indicate improvement in the condition of the patient who has anorexia nervosa?
1. The patient has gained weight.
2. The patient weighs herself every day.
3. The patient eats all the foods served to her.
4. The patient asks the parents to bring her favorite foods.

Choose the option that shows progress toward the goal (in this condition, it is weight gain that is expected).

When you do not know the answer, choose what will cause the least harm.

Example: The nurse suspects abdominal wound dehiscence when lifting the edges of the patient's dressings. What should the nurse do next?

1. Tell the patient to remain quiet and not cough.
2. Offer a warm drink to help relax the patient.
3. Place the patient with feet elevated.
4. Change the dressing.

Option 1 is the best answer, because it will not add damage that could happen with changing the position or the dressing.

Take care of the patient first, not the equipment or the family (unless a family member is the focus of the question).

If one option has generally, usually, tends to but other options do not have these qualifiers, use the one option that does have the qualifier as the best answer.

Look for a similar word or phrase used in the question and in one of the options. For example, if the question states that the patient is on an intermediate-acting insulin (NPH), and the stem asks for its peak action, look for a middle time—between a choice of: 4 hours after the injection, 6-12,12-14, or 15-18. Choose 6-12 hours (as the midpoint).

If two options say the same thing, neither can be the answer because both are distractors.

Example: What might the nurse expect to see when a patient with cirrhosis is hospitalized with ascites?

1. Patient is likely to be anorexic.
2. Patients intake will be poor, especially if served large portions.

You can eliminate both of these options because they are saying the same thing in different words: the patient is likely to be uninterested in eating.

Don't "pass the buck"—think what is a nursing action that an RN can do before calling the MD.

Example: After surgery, a patient with diabetes complains of nausea, appears lethargic and flushed, with BP 108/78, P 100, R 24 and deep. What is the next action?

1. Call the MD.
2. Check the patients glucose.
3. Give an antiemetic.
4. Change the IV infusion rate.

The nurse should assess (option 2) before calling the MD (who may then order an antiemetic, option 3, and alter the IV infusion rate, option 4).

Focus on key words in the sfem of the question as your clue:
- Best
- Essential
- Highest
- Immediate
- Least likely
- Most
- Most appropriate
- Most likely
- Vital

"Action" does not always mean choose an "implementation" type of answer. The question may ask: "What is the best nursing action?" However, the answer may be an "assessment" option.

Example: What is the best action for the nurse to take when a mother at the clinic reports that her diabetic child is hyperglycemic in the morning (215 mg/dL), although the child has been well controlled with NPH and regular insulin before breakfast and dinner?

1. Suggest that the mother give the bedtime snack earlier.
2. Suggest that the insulin be given later in the evening.
3. Suggest that they continue with the same regimen.
4. Check the blood sugar now, and suggest that the mother check it during the night.

Choose "check," which is an "assessment" response (option 4), although the question (the stem) is phrased as an implementation ("best action" is an implementation).

Remember the nursing hierarchy. Go to the next line of nursing authority (e.g., staff —> charge nurse; LPN/LVN —» staff nurse) when the question asks to whom to report a situation; for example, if the question is about an LVN/LPN, the best answer is to report to the staff nurse.

When the question includes lab values, ask yourself whether the given value is "Oh! Oh!" (meaning too high or too low); or "Eh" (meaning not a particular problem). For example, a serum K+ of 8.5 is "Oh! Oh!" (too high).

Prevention is a key concept (e.g., when the question deals with infection control, and in health teaching).

Example: The primary objective in ileostomy teaching with a patient during early postoperative period is to:

1. Facilitate maintenance of intake and output records.
2. Control unpleasant odors.
3. Prevent skin excoriation around the stoma.
4. Reduce the risk of postoperative wound infection.

Choose "prevention" (option 3), which in turn may prevent contamination of abdominal incision (option 4). Options 1 and 2 are secondary objectives.