CORNERSTONES How to Use Critical Thinking to Pass the NCLEX

1. CORNERSTONESHow to Use Critical Thinking to Pass the NCLEX

2. SCHEDULE • Session One (8am – 3pm) 1. Course Introduction 2. Content Review (8 taxonomies) • Session Two (8am – 3pm) 1. Test Taking Skills 2. Critical Thinking Skills • Session Three (8am-3pm) 1. Practice Questions • Session Four (8am-3pm) 1. Practice Questions

3. Session One Course Introduction Content Review

4. COURSE PURPOSE • The Cornerstones Course will provide the nursing student sufficient content, test taking skills, and critical thinking skills needed to successfully pass the NCLEX-PN exam. • The student will need to practice from 2000 to 3000 questions after this course is completed, and before the NCLEX exam. • The integration of the Cornerstones’ skills and recommended practice builds the confidence needed to successfully pass the NCLEX.

5. The Purpose of the NCLEX The purpose of the NCLEX exam is to verify the ability to be an entry level, generalist, minimally safe, and therapeutically effective nurse. It is a function of each States’ Nurse Practice Act. The outcome is “licensure”. Basically, it means the new nurse can take care of anybody, anywhere, any age and gender, with any wellness or illness issue. The NCLEX is about fundamental nursing science and nursing art, and basic skills.

6. The Four Cornerstones • CONTENT • Memorize and recall 60-80% of what was learned. • Covers 8 taxonomies • Coordination of Care • Safety & Infection Control • Health Promotion & Maintenance • Basic Care & Comfort • Psychosocial Integrity • Physiological Adaptation • Pharmacology • Reduction of Risk Potential

7. The Four Cornerstones 2. TEST TAKING TOOLS • NCLEX is a “standardized: exam and requires special skill set. 3. CRITICAL THINKING TOOLS • Definition: gathering data to make a decision. • Similar to the Nursing Process, these strategies represent a “new” process you must learn. 4. CONFIDENCE

8. NCLEX is a UNIQUE EXAM Nursing School NCLEX • Uses rote memorization to answer questions. • Topic (stem word, key word, subject) is included by name. • Very little use of “distraction” in question or “traps” in answers. • Uses application of knowledge to answer questions. • Topic is usually “hidden”. • Uses much more “distraction” in question, and more “traps” in answers.

9. NCLEX is a UNIQUE EXAM Nursing School NCLEX • Limited use of “basic critical thinking” in answering questions. • Goal is to pass using one raw score. • An “A” is typically 90-100; a “D” or “F” is failing, usually <70. • Uses three levels of “complex critical thinking” in answering questions. • Goal is to pass each of the 8 taxonomies, using 8 scores. • An “A” is 65, and must be achieved on each of the 8 taxonomies.

10. NCLEX is a UNIQUE EXAM Nursing School NCLEX • Time allotment: 1 question per minute. • Read question, identify topic, answer question. • Does not require answer validation. • Time allotment: approximately 1 question per 1.5 minutes (5 hours maximum). • Read question, read answers, identify topic, apply critical thinking tools, choose answer. • Validate answer.

11. NCLEX is a UNIQUE EXAM • 85 minimum questions; 205 maximum questions. • If the computer cuts off at 85 questions, outcome is usually “pass”, though it is also possible to “fail” or “nearly pass” in 85 questions. • If all 205 questions must be used, outcome is usually “fail” or “nearly pass”, though it is also possible to “pass” in 205 questions. • It is possible to “pass” 7 taxonomies, but “fail the 8th, thus failing the entire NCLEX.

12. NCLEX is a UNIQUE EXAM • To construct a question/answer set, the item writer uses three boxes: • Taxonomy (8 categories) • Critical thinking levels (Bloom’s Taxonomy) • Topical/Strategic/Both (3 possibilities) • Bloom’s Taxonomy (Recognition/Recall – Understanding – Application – Analysis)

13. SCORING General Rules Based on eight different scores (8 taxonomies), not just one raw score. Must show competence in all eight taxonomies. Categories: Passing, Nearly Passing, Did Not Pass. (only “passing” passes).

14. SCORING“Climbing the Stairs” • Minimum 85 questions • 8 taxonomies (approximately 10 questions/taxonomy) • 3 levels of critical thinking (3 questions for each level within each taxonomy) • 65 indicates “passing” score (must correctly answer 6-7 questions out of the 10 questions, and at all three levels of critical thinking). • Questions 86 – 205 focus on getting up the “stairs” at least twice out of multiple attempts.

15. CONTENTHelpful Hints 1. Coordination of Care: Advanced directives/DPOA/MDPOA/living will Chain of command Nurse Practice Act (scope of practice) Assault and Battery Restraints Multidisciplinary team Negligence Impaired nurses False Imprisonment Patient privacy/confidentiality/HIPPA Basic rules of therapeutic communication Patient Advocacy Patient Rights Information technology

16. CONTENTHelpful Hints 2. Safety & Infection Control: Personal protective equipment Isolation precautions Hand washing Infection control Use of antimicrobial therapy Radioactivity Hazardous material contamination Emergency preparedness Accident/injury prevention Ergonomics Home safety Medical/surgical asepsis Incident reporting Safe use of equipment Security plan Standard precautions

17. CONTENTHelpful Hints 3. Health Promotion & Maintenance: Growth and development (physical and psychosocial) Immunizations Ante/intra/post partum care Newborn care Data collection Disease prevention Lifestyle choices Human sexuality Family planning Expected body changes Screening programs High risk behavior Self care

18. CONTENTHelpful Hints 4. Basic Care & Comfort: Range-of-motion Postoperative leg exercises Positions Assistive devices Elimination Rest/sleep Comfort measures Mobility/immobility Palliative care Personal hygiene Nutrition/oral hydration

19. CONTENTHelpful Hints 5. Psychosocial Integrity: Therapeutic communication in the psych millieu Abuse/neglect Behavior management Sensory/perceptual alterations Situational role changes Coping mechanisms Crisis intervention Cultural awareness Unexpected body changes End-of-life care Grief and loss Religious/spiritual influences Stress management Substance abuse Emotional support systems Suicide/violence precautions

20. CONTENTHelpful Hints 6. Physiological Adaptation Alterations in body systems Basic pathophysiology Fluid/electrolytes Acid/Base Medical emergencies Radiation therapy Unexpected responses to therapies

21. CONTENTHelpful Hints 7. Pharmacology: IV fluids Starting IV’s Dosage calculations Adverse side effects and side effects Contraindications and compatibilities Expected outcomes Medication administration Drug mechanisms of action

22. CONTENTHelpful Hints 8. Reduction of Risk Potential Preventing future complications Diagnostic tests Lab values Therapeutic procedures Vital signs

23. CONTENTHelpful Hints • CRAM List: • Everybody crams before any big exam, but there is an easy way to do it. • As you begin to study, including completing practice questions (recommendation is 1500 questions), start keeping an “inventory”. • This inventory should include five primary categories of topics: pathophysiologies, drugs, medical procedures, labs, and the topics of Coordination of Care. • When “cram” time arrives, there will exist a “short list” of relevant NCLEX topics. • Resources include ATI, Kaplan-PN, studyguidezone.com

24. CONTENTHelpful Hints • Pharmacology rules: • Upper/Downer Rule & Overdose-to-Withdrawal Continuum EXAMPLE: A young adult brings his friend into the emergency room and states that his friend has been using heroin. The nurse would be MOST concerned if which of the following was observed? a. dilated pupils, irritability, tremors b. pinpoint pupils, respiratory depression, hypotension c. restlessness, diaphoresis, nausea/vomiting d. dilated pupils, euphoria, diaphoresis

25. CONTENTHelpful Hints Pharmacology rules 2. Hypersensitivity-to-Allergic Reaction-to-Anaphylaxis Continuum EXAMPLE: The school nurse attends a picnic for elementary students. A 10 year-old child begins screaming, “I’ve been stung by a bee”. The nurse notes the child has a large welt at the site of the bite and a raised red rash on the extremity. As the nurse examines the child, the states, “ I am feeling really hot.” Which of the following actions should the nurse take FIRST? a. remove the stinger and apply ice to the site b. assess the rate and quality of respirations c. administer 0.3mg of epinephrine subcutaneously d. ask the child about previous reactions to bee stings

26. CONTENTHelpful Hints • Pharmacology rules • Drug-Drug Interaction, Drug-Food Interaction, Drug-Body Interaction EXAMPLE: The nurse admits a patient with a history of breast cancer and type 1 diabetes. The nurse is aware that careful monitoring of the patient’s blood sugar is necessary if the patient receives which of the following medications? a. prednisone b. captopril c. nifedipine d. amoxicillin EXAMPLE: The nurse is teaching a patient about phenelzine(Nardil). The nurse should instruct the patient to avoid which of the following medications? a. ibuprofen b. pseudoephedrine c. acetaminophen d. aspirin

27. CONTENTHelpful Hints Pharmacology rules 4. Central nervous system v/s Peripheral nervous system drugs EXAMPLE: The nurse cares for a client receiving carbidopa/levidopa (Sinemet). The nurse is MOST concerned if the client states which of the following? a. “ I take a daily multivitamin,” b. “ I exercise daily.” c. “ I take kava for insomnia.” d. “ I eat several small meals a day.”

28. CONTENTHelpful Hints Pharmacology rules 5. Cross Sensitivity EXAMPLE: A 65 year-old man has an allergy to penicillin and sulfa. Which of the following medications, if ordered by the physician, should the nurse question? a. tetracycline b. sulfisoxazole c. azithromycin d. ciprofloxacin

29. CONTENTHelpful Hints Psychosocial rules: Identify whether question is about safety, setting boundaries, or reality testing. EXAMPLE: A patient with chronic schizophrenia tells the nurse, “ The voice is telling me that I’m a bad person. I can’t get it to stop talking!”. Which of the following responses by the nurse is BEST? a. : Does the voice tell you why you are such a bad person?” b. “ You hear a voice. I don’t hear anything. We have other things to talk about.” c. “ It is important for you to let these voices go so that you can get well.” d. “ That’s not what the voice is saying. It is saying you are a good person.”

30. CONTENTHelpful Hints • Psychosocial rules: • Effective therapeutic communication (in the psych millieu) requires that the nurse not confront, nor enable a patient. EXAMPLE: The nurse is caring for a patient with a diagnosis of schizophrenia. The patient points to another patient and says to the nurse, “ Do you see that person over there who is shaking and pointing? She is possessed by the devil and is trying to get my soul”. Which of the following responses by the nurse is BEST? a. “Is there something about her that makes you feel bad about yourself?” b. “That sounds like a scary thought. She is shaking because of her illness.” c. “ Something about her seems to frighten you. Try to ignore her.” d. “ No, I don’t see it that way. What makes you think that?”

31. CONTENTHelpful Hints • Psychosocial rules: • Never leave any patient “alone”. For all psychiatric diagnosis, except Depression, do not try to involve the symptomatic patient with other patients, or in busy activities. EXAMPLE: Several days after being admitted for Depression, a patient is observed sitting alone in the dining room, and the nurse notes the patient has not finished his meal. Which of the following actions is MOST appropriate? a. sit with the patient during meals. b. ask the family to bring in favorite foods. c. permit the patient to eat alone until the patient becomes more comfortable. d. allow the patient to determine if and when he will eat.

32. CONTENTHelpful Hints Psychosocial rules 4. Decrease sensorium for all neurological and neuropsych patients. EXAMPLE: As the nurse admits a patient to the psychiatric unit, the patient becomes agitated and belligerent. The nurse should take which of the following actions? a. obtain order for a antipsychotic drug b. place the patient in a dimly lit room with the door ajar c. ask the patient to calm down d. explain the unit rules

33. Session Two Test Taking Skills Critical Thinking Skills

34. TEST TAKING SKILLS A typical test question requiring critical thinking has three parts: 1. Introduction 2. Important Data 3. Actual Question Example: The nurse in the outpatient clinic receives a phone call from a mother of a 4 year-old. She tells the nurse her child has a dry, “barking” cough, a temperature of 101.0F, is very irritable, and has very little appetite. Which of the following indicates the nurse’s BEST response?

35. TEST TAKING TOOLS • Remember, there are many item writers and styles of questions. • Process of elimination – must use. Just as important to know why the wrong answers are wrong as it is to know why the correct answer is correct. • Benchmark answer – what your “gut” tells you is correct. • Beware of “all” or “nothing” answers. • Comma, comma, comma.

36. TEST TAKING TOOLS • Note use of negative words and odd numbers. • Identify distraction in questions, and traps in answers. • Identify “buzz words” (i.e. should intervene, discharge teaching is effective, further teaching is necessary). • Do not read into the question. Can be creative with the answers. • There will be 10 “alternate” questions on the NCLEX.

37. TEST TAKING TOOLS • There will be alternative style questions on the NCLEX: fill in the blank, select all that apply, hotspots, ranking, chart, auditory) • Old v/s New. • The “repeat” question. • Know that all correct answers have textbook rationale • “Guessing” v/s “Educated Guessing”. • Can’t change, can’t go back, can’t skip. • Drop down calculator; dry board/paper.

38. TEST TAKING TOOLS • Questions of High Anxiety ( #1 and #86). • Time allocation: questions 1-85 (150 seconds); questions 86-205 (70 seconds). Take a timepiece and keep up with your time. • Recommendation: practice 2000-3000 questions (content and critical thinking). • Visit test center prior to test date. • Say to yourself repeatedly, “ It’s just a test of minimal competency; I know I am more than minimally competent .”

39. TEST TAKING TOOLS • Every 20 questions, take 3 deep breaths as you close your eyes. • If you get frustrated or anxious, say to yourself, “ It’s normal to feel this way, but I am not going to let that defeat me.” • If video camera security makes you nervous, either smile at the camera or act like you are a spy. • If it helps to answer a question, “act out” the answers (i.e. crutch walking).

40. TEST TAKING TOOLS Do NOT cram at least 24 hours prior to the test date/time. It wastes 60% of the energy you will need on test day. Don’t drink any diuretic beverages on test day; eat only minimal simple sugars; get the RDA of B-complex vitamins. No one expects to “fail”. But, be realistic, even if failure of the NCLEX happened, one can always take it again.

41. CRITICAL THINKING TOOLSA New Process to Learn Content questions = 75% Critical Thinking questions = 25% Tool One: Identify topic (also called stem, key word, subject). Tool Two: Assessments v/s Interventions Tool Three: Physical v/s Psychosocial (Maslow). Tool Four: ABC’s Tool Five: Validation

42. CRITICAL THINKING TOOLS • Tools, 2, 3, & 4 are “big” tools and are optional. • Tool 5 are “little” tools and must be used. • NCLEX questions may use big tools, little tools, or both to determine correct answers. • Possible combinations: (1,2,3,4,5), (1,2,3,5), (1,2,4,5), (1,2,5), (1,3,4,5), (1,3,5), (1,4,5), (1,5). • Some questions require more critical thinking in the question (topical), or some require more critical thinking in the answers (strategic).

43. CRITICAL THINKING TOOLSTool One – Identify Topic • Topic is usually “hidden”. • Read entire question/answer set once or twice before deciding upon topic. • Clues to the topic are often found in the answers. • Identify distraction. • Identify traps (looks, feels, or sounds good). • Look for “specific signs/symptoms in question as probable topic. • Locations (i.e. Med/Surge) don’t matter.

44. Tool One – Identify Topic Times and dates in the question are important. Ages or reference to age (i.e. older) in the question are important. Ages in the answers are traps, except for questions about risk factors. Identify “priority words” (i.e. MOST, FIRST, BEST, INITIAL, HIGHEST).

45. Tool One - Identify Topic • Don’t read into the question. Don’t play “what if” with the data in the question. • Main types of questions: 1. Content (no real need for critical thinking; you know this or you don’t). 2. Priority Action (uses a priority word in the question and usually has word “actions”); clue to use Tool Two next. 3. Patient Priority (use Tools 3, 4, abnormal/normal: expected/unexpected).

46. Tool Two – A/I Are answers assessments or interventions. Nursing Process indicates assessments come before interventions, so analyze assessment answers first. Definition of assessment: an action done to gather data in order to devise an intervention.

47. Tool Two – A/I Note “medical” interventions v/s “nursing” interventions. Note “subjective” assessment v/s “ objective” assessment.

48. Tool Three - Maslow Determine if answers are physical or psychosocial. Physical answers always win over psychosocial answers. Note if pain is topic, only two physical pain conditions: cardiac, sickle cell crisis.

49. Tool Four – ABC’s Airway, breathing, circulation. Answers aren’t always so obvious. For example, “facial edema” infers airway. For example, “restlessness” infers hypoxia, indicating a breathing issue.

50. Tool Five - Validation NCLEX is NOT the REAL WORLD!!!!!