7 Types of Alternate-Format NCLEX Questions (and How to Dissect Them) – Part Five

Just when you thought you could leave math behind forever, nursing gives you a reason to take out your calculator. Mathematical calculations are everywhere in patient care. Some are easy, like calculating intake and output or monitoring trends in lab work and vital signs. Perhaps the most quintessential (and difficult) nursing math is administering medication.

If you’re like me, you hate math. I did not pursue nursing to do complex problem solving. My brain is wired in such a way that a lot of math doesn’t make much sense to me. But if I can set up and solve nursing-related math problems, you can too! The key to acing nurse math is to memorize a few simple mathematical operations. Fear not, we’ll go through the whole process (together, of course!) right here.

Throughout this five-part series on alternate-format questions, we’ve covered everything the test can throw at you. We started with a brief introduction to the NCLEX in part one, followed by detailed explanations of audio, chart/exhibit, graphic, and hot spot questions in part two. Parts three and four focused on multiple response and ordered response questions, respectively.

And now, we’ve arrived at part five, the final piece of the NCLEX alternate-format question puzzle. The most difficult one, to be sure, but certainly not impossible. Read on to learn more about fill in the blank questions, or as I like to call them, math questions.

7.) Fill in the Blank Questions

The NCLEX doesn’t waste its time testing you on easy operations like calculating intake and output. It will test you on the hard stuff: medication dosage. Incorrect dosage calculations can cause real harm to real patients in real life, so you have to know how to do them correctly. When a provider writes an order for a dopamine drip at 20 mcg/kg/minute and you have to determine the rate in mL/h, the pharmacy doesn’t give you four (i.e. multiple choice) options. You have to do the math and figure it out.

Remember, the sole purpose of the NCLEX is to determine if you have the skills and knowledge to succeed as a nurse. Fill in the blank questions are the best way to determine if you can properly calculate medication dosages.

Believe it or not, the NCLEX does not want you to fail. On test day you will have access to a calculator so you won’t have to do any calculations in your head. You will also have some scrap paper to write things down. All you have to know is how to get the answer. The following three math operations will help you get there.

Math Operation #1: Conversions

To answer fill in the blank questions, know your basic conversions. In the medical world, the metric system is king. Fluids and medicines are measured in liters and grams. However, most Americans are more familiar with teaspoons and ounces. Since nurses regularly encounter both systems of measurement, you need to be able to conduct simple conversions. You should memorize the following:

Conversions

You may also be asked to make simple conversions within the metric system itself. Medications are often expressed as grams, milligrams, or micrograms. Fluids may be measured in liters or milliliters. As an example, you may be asked to administer a weight-based medicine in mL/kg, but you see that your neonatal patient’s weight is expressed in grams! You’ll have to convert the weight from grams to kilograms in order to calculate the appropriate dosage.

Luckily, converting within the metric system is really easy. First, it’s important to know the correct order of prefixes. Let’s use weight (grams) as an example:

Think of the center (gram) as your baseline. As you move your eyes down the line to the left, the units get bigger. A kilogram is heavier than a gram. As your eyes move down the line to the right, the units get smaller. A milligram of medicine is a tiny amount compared to a gram.

Now that you know the correct sequence of prefixes, you can quickly convert between different measurements because each is a multiple of 10! A decagram is 10 times bigger than a gram. A centigram is 100 times smaller than a gram. If you think of the weight as a decimal, it makes converting even easier. Each decimal place is a multiple of 10, so it matches up perfectly.

For example, say you have a neonatal patient that weighs 4500 grams. You need to record the weight in the chart as kilograms.

Express the weight as a decimal: 4500 grams

Next, refer back to the chart above and you’ll see you need to move the decimal place 3 spaces to the left to convert to kilograms.

4500 grams = 4.5 kilograms

Just for fun, let’s convert the weight to micrograms. By using the original chart, you’ll know to move the decimal point 3 spaces to the right.

4500 grams = 4,500,000 micrograms

The same prefixes apply to fluids (liters) and length (meters), so you can easily convert from liters to milliliters, or meters to kilometers, by using this same process.

Math Operation #2: Proportions

A proportion is a simple mathematical formula that helps you determine parts of a whole. Proportions come in handy in nursing because you will frequently encounter situations where the contents of a medication vial do not match the ordered dosage. For example, if you have a vial of heparin that contains 5,000 units/mL. The doctor orders you to administer 3,000 units. Obviously, you won’t administer the entire milliliter of medicine, but exactly how much will you give? Set up a proportion to help you.

To solve a proportion, you need to set up two matching fractions, like this:

You’ll notice that the top of each fraction is in milliliters and the bottom of each fraction is in units. The fraction on the left represents how much is in the vial, and the fraction on the right represents how much you need to give the patient. You need 3000 units, or X milliliters.

To solve for X, you cross multiply. This means multiplying the top of one fraction by the bottom of the other, and vice versa:

Your fractions become an equation.

3000*1 = 5000X

Now you need to get the x by itself through division.

You’ll administer 0.6 mL to the patient.

Follow these same steps anytime the ordered dosage of a medication does not match the contents of the vial or when you need to determine the parts of a whole.

Math Operation #3: Weight-Based Calculations

You will also need to know how to calculate weight-based medication dosages. When calculating a dosage based on weight, you may need to use conversions or proportions, or both. Remember that all the information you’ll need is contained within the question on the NCLEX exam. You just have to know how to set it up. Take a look at this question:

The 39-week-gestation neonate is born to a mother with chorioamnionitis. The provider has ordered ampicillin 75 mg/kg/day in divided doses every 8 hours and administered intravenously. The neonate weighs 4.2 kg. How many milligrams does the nurse administer with each dose? Enter your answer using a whole number.

After reading the question, pause for a moment and take a breath if you’re feeling overwhelmed. What is this question asking you to do? You’ll need to calculate a pediatric weight-based dose of medication. No problem, just follow some simple steps.

Step 1: Do you need to do any conversions?

In this question, you’ll notice the provider ordered the medication in kilograms and the patient’s weight is already given in kilograms. No conversions are necessary. Move on to step two.

Step 2: Calculate your dose.

Thus, the neonate will receive a total of 315 mg of ampicillin each day. But remember, you aren’t finished because the question asked how much medicine the patient will get with each dose. The question states the patient will receive doses every 8 hours, or 3 times a day.

Divide the daily amount of milligrams by the number of doses.

Step 3: Round your answer, if necessary.

The question tells you to round your answer to the nearest whole number. Happily, no rounding is necessary. You would enter 105 into the answer blank.

Put it All Together

Let’s look at another weight-based calculation that uses both conversions and a proportion.

The 25-week-gestation neonate is ordered to receive ampicillin 100 mg/kg/day intravenously, divided into doses every 12 hours immediately after birth. The neonate weighs 745 grams. The pharmacy dispenses ampicillin in a 5 mL vial that contains 125 mg. How many milliliters will the nurse administer with each dose? Round your answer to the nearest tenth decimal.

Step 1: Do you need to do any conversions?

The order is given in kilograms, but the neonate’s weight is given in grams. Convert grams to kilograms. 745g = 0.745 kg

Step 2: Calculate your dose.

In this case, the question wants you to convert from grams to milliliters. So you’ll need to set up your proportion to calculate the dose you’ll give in mL:

Step 3: Round your answer, if necessary.

The question asks you to round you answer to the nearest tenth. Therefore, you’ll administer 1.5 mL.

That’s all there is to it. When taking the NCLEX, be sure to read each question carefully. Take a deep breath and slow down; math can be intimidating! Determine what the question is asking.  When the doctor orders a medication and the dosage doesn’t match up with the amount of drug in the vial, simply set up a proportion and cross multiply. In other situations, you must calculate the dosage based on weight, plugging in the numbers and then multiplying or dividing as necessary. So practice. Practice as much as you can. You will certainly use these skills in your future nursing career.

You’re NCLEX-Ready!

This concludes our series on alternate-format NCLEX questions. We hope you feel more comfortable and confident in answering these questions. Remember, alternate-format questions make up a smaller but potentially significant part of the exam. On test day, while those less prepared than you will be sweating bullets and freaking out, you’ll feel confident, relaxed, and focused on your goal: passing the test and getting your nursing license!