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Four Steps for Dissecting NCLEX® Questions

Meghan Jenkins, MSN, FNP

Updated

Reviewed by NursingEducation Staff

The NCLEX® is one of the final hurdles to overcome on the journey toward becoming a registered nurse. The exam is universally feared, and most nurses will admit (sometimes grudgingly) that it was the most challenging exam they’ve ever taken. The test is supposed to be taxing; ensuring only the safest nurses are able to care for patients.

When taking the NCLEX®, you need to know more than just facts. Anyone can memorize the nursing process or Maslow’s Hierarchy of Needs. The best nurses know how to use their knowledge and critical thinking skills to make important decisions on the job. The NCLEX® assumes that test candidates already have knowledge. You must now prove you can go a step further.

Know the Enemy

The key to defeating the NCLEX® is to understand how the test works. The best test takers look for tips and strategies to improve their critical thinking and decision-making. Looking at sample questions helps you become more familiar with the test format, which can give your confidence a much-needed boost on test day. At this point, your focus shouldn’t be increasing knowledge—that’s what the last few years of school were for! If you understand how to dissect the NCLEX® question, it may not even matter if you know the answer—so long as you understand the heart of what it’s asking.

Each standard, multiple-choice NCLEX® question is divided into two parts: one “stem” and multiple answer options. The stem can range in length from a single sentence to an entire paragraph. The answer options are mostly distractors, except for the one correct choice.

Study the sample question below. We’ll come back to it at the end of the article.

Stem: The patient complains of heat intolerance, weight gain, and hair loss. The nurse notes periorbital and generalized non-pitting edema. The patient’s blood pressure is 98/64 mmHg and heart rate is 48 bpm. The nurse anticipates which lab result?

So how do you determine the best answer? Follow these four simple steps: assess the question, consider priority, reword the question, and evaluate the answer choices.

Step 1: Assess the Question.

When faced with an NCLEX® question, the first thing to do is read the stem, whether it’s a single sentence or an entire paragraph. Determine if the stem is positive or negative. A positive stem asks what is true, while a negative stem looks for what is false. Each type of stem will have certain keywords, like these:

Positive Negative
Appropriate
True
Indicated
Understand
Not, Never
Further
Least
Avoid
Contraindicated

Positive: Which statement most appropriately reflects how the nurse documents these findings?

Negative: Which statement by the client indicates to the nurse that further teaching is necessary?

In both example questions, the positive or negative qualifier is in bold print. The NCLEX® does use bold print for certain keywords in the test, such as best, most, essential, first, priority, immediately, highest, initial, next, refute, increased, decreased, and support. However, qualifier words can be easy to miss, and best practice is still to read the full question.

Step 2. Consider Priority.

After you assess the question and determine if it contains a positive or negative stem, the next step is to look for priority indicators. An NCLEX® question may ask the reader to address priority by using words such as first response, most important, best, etc. In other words, which answer choice is the most correct?

The Nursing Process. The Nursing Process is perhaps the most fundamental tool for guiding decision-making and action. Remember the ADPIE mnemonic.

The steps of this process should be implemented in order, meaning that assessment comes first. Remember: always assess before you implement.

For example:

The patient in the intensive care unit who is intubated and mechanically ventilated abruptly requires a drastically increased fraction of inspired oxygen (FiO2) and is hypoxic, hypotensive, and tachycardic. Which intervention does the nurse perform first?

First is an indicator of priority. A, B, and D are actions, meaning implementation. Auscultation is an aspect of assessment, and assessment always comes first. Therefore, the correct answer is C.

Step 3: Reword the Question.

Once you’ve fully assessed the stem, you need to figure out the heart of what you’re being asked. An easy way to do this is to reword the question. When the stem of an NCLEX® question is the length of a paragraph, you can easily get bogged down in the details. When you finally come to the end of the question, rephrasing the question in your own words can help simplify matters. For example:

The nurse is teaching the nursing student the care of a patient with a tracheostomy. Which action by the nursing student when preparing to change the tracheostomy tube would prompt the nurse to intervene immediately?

You’ve already looked for keywords and recognized the negative qualifier intervene immediately. Now condense the paragraph into a more manageable question, such as this: Which trach care action performed by the student is wrong?

Here’s another example:

The 6-month-old infant is admitted to the pediatric intensive care unit with a diffuse purpuric rash and prolonged bleeding. The nurse notes the fingers on the right hand are pale and cool to the touch. Which question asked of the parents will be the most helpful in diagnosing this patient’s condition?

You have here the positive indicator most helpful. Reduce the long paragraph into a simpler question, like this one: Which answer option best aids in the diagnosis of purpuric rash and bleeding?

Taking a complex question and reducing it into a single, manageable sentence isn’t always easy. You’ll need time and practice to develop this kind of skill. Putting in the work on the front end will save you a lot of time and stress on test day.

Step 4. Evaluate the answer choices.

Now that you’ve read the entire stem and condensed it into a simple question, you’re ready to focus on the answer options. We have lots of tips and tricks to help you pick the best choice.

A. Eliminate incorrect answer choices. You might be thinking, easier said than done. However, if you follow step two and reword the question to its simplest form, you might be surprised at how some answer choices become obviously wrong. Take a look at the following question:

The patient who experiences frequent episodes of atrioventricular nodal reentry tachycardia (AVNRT) that do not cause hemodynamic compromise is being discharged. The nurse is supervising the student nurse providing discharge teaching to the patient. Which method for self-treatment of AVNRT, if taught by the student nurse, would prompt the nurse to intervene immediately?

You’ve assessed and reworded the question to: Which option shows incorrect teaching for AVNRT? Options A, C, and D are all techniques of valsalva or vagal maneuvers, which are safe to perform at home. However, option B is the written technique for carotid massage, which can actually harm the patient when incorrectly applied. Because it cannot be performed safely at home, the correct answer is B.

B. Look out for repetition. Eliminate answers that are repetitive. If two or more answer options use different words but say essentially the same thing, they are probably wrong. Look again at the answers from the previous question:

Though different words are used, A, C, and D each describes techniques that promote the same goal. Thus, these options essentially cancel each other out.

C. Always promote safety. Safety is also a top priority when evaluating answer choices. To ensure patient safety, a nurse must meet all basic needs, reduce potential hazards, and reduce the risk of infection/transmission. It is also important to factor in the ABCs (Airway, Breathing, Circulation). The option that promotes patient safety is generally the best choice. For example:

The older adult has been admitted with right-sided weakness and a history of falls. Which nursing diagnosis has the highest priority for this patient?

Patient safety is always a priority. The correct answer is B.

D. Pay attention to opposites. When considering answer choices, look for opposite answers. Often, one of the two opposite choices is correct. For example:

Immediately after a percutaneous liver biopsy, the nurse places the client in which positions?

Your eye moves immediately to choices B and D, since they are opposites. Because the liver is on the right side of the body, reclining accordingly will help apply pressure to the liver and minimize bleeding. The correct answer is B.

E. Throw out absolutes. There are no guarantees in life or in nursing. When answer choices contain absolutes—like always, only, never, or all—those answers are often wrong. For example:

The nurse is providing preoperative teaching to the parents of a neonate diagnosed with short-segment Hirschsprung disease. Which statement by the patient’s mother indicates an understanding of the education?

Answer choices A and D use the word will as an absolute. There is no guarantee that the patient will have an ostomy or a fistula, so those answers can be thrown out. While option B does not use an absolute, it suggests that an ostomy is a certain outcome. The correct option is C.

F. Ignore the unrelated. For a standard multiple-choice NCLEX® question, only one solution is correct. As such, you know that three out of every four answer choices are distractors. Sometimes an incorrect answer can be eliminated because it has nothing at all to do with the question. For example, if a question asks the reader to evaluate flank pain but presents an answer option related to the neurologic system, that choice can be eliminated.

G. WWTS: What Would the Textbook Say? Keep in mind that the NCLEX® is a “by-the-book” test. You always have unlimited time, resources, and staff—as far as the test is concerned. While nurses might do things a certain way in the real world, the test is only interested in what the book says. An accepted shortcut is never the right answer in the NCLEX® world. If you aren’t sure of an answer, don’t just ask yourself what is done at your hospital. You can run into trouble because real-life practice may not match the advice given by your trusty textbook. For the NCLEX®, always follow the book!

H. Be careful of “call the physician.” In some scenarios, calling the physician is an answer option, and it’s probably something a nurse would do anyway. However, the nurse should often do something else before calling the doctor. For this reason, calling the doctor can definitely be the wrong answer. The NCLEX® is not known for acknowledging the easy way out.

The Four Steps in Action

Let’s apply these four steps to our first sample question:

The patient complains of heat intolerance, weight gain, and hair loss. The nurse notes periorbital and generalized non-pitting edema. The patient’s blood pressure is 98/64 mmHg and heart rate is 48 bpm. The nurse anticipates which lab result?

Step 1: The question has the positive indicator anticipates.

Step 2: The question does not address an issue of priority.

Step 3: Reword the question to “Which lab result best explains heat intolerance, weight gain, hair loss, and edema?”

Step 4: Ignore unrelated answer choices. A patient with elevated hemoglobin and sodium would present with symptoms much different than the ones listed above (such as dizziness and fatigue, among other things), thus options B and C can be quickly eliminated. Heat intolerance, weight gain, hair loss, and edema are commonly associated with hypothyroidism. The nurse would expect to see an elevated TSH.

The correct answer is A.

Practice, Practice, Practice

When prepping for the NCLEX®, read through as many sample questions and tests as you can. Critical thinking improves with practice and repetition, just like any other skill. You already have the knowledge from years of nursing study; it’s now time to put it all together so that when test day comes, you can tell yourself with confidence, “I’ve seen this before. I got this!”

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