NCLEX: Orientation

As a Starting Point

This study guide can be used in early review when a longer study period is needed to fill in gaps of knowledge. One cannot remember something if one does not know or understand it. A lengthy review before the examination allows students time to rework and organize notes accumulated during 2 to 4 years of basic nursing education. In addition, an early review allows time for self-evaluation. We have provided questions and answers to help students identify areas requiring further study and to help them integrate unfamiliar material with what they already know.

As an Endpoint

This guide series can also be used for a quick review

(a) to promote retention and recall and

(b) to aid in determining nursing actions  – appropriate to specific health situations. During the time immediately preceding the examination, the main objective might be to strengthen previous learning by refreshing the memory. Or a brief overview may serve to draw together the isolated points under key concepts and principles in a way that shows their relationships and relative importance.

As an Anxiety-Reduction Tool

In some students, anxiety related to taking examinations in general may reach such levels that it causes students to be unproductive in study and to function at a lower level during the actual examination. Sections of this chapter are directed toward this problem and provide simple, practical approaches to the reduction of general anxiety. For anxiety specifically related to unknown aspects of the licensure examination itself, the section on the structure, format, and mechanics of the RN examination might bring relief through its focus on basic examination information.
For anxiety related to lack of confidence or skill in test-taking “know-how,” the special section on test-taking techniques may be helpful.

As a General Study Guide and as a Refresher for Nurses Not Presently in Practice

Many nursing students will find this review book useful throughout their education as a general study guide as they prepare client care plans and study for midterm and final examinations. It will help them put information into perspective as they learn it. And nurses who have not been in practice for several years will find it a useful reference tool and review device.

Where to Begin

In using this review book to prepare for the licensure examination, the nurse must:

1. Be prepared mentally.

  • Know the purpose of the examination.
  • Know the purpose of reviewing.
  • Anticipate what is to come.
  • Decide on a good study method—set a study goal before beginning a particular subject area (number of pages, for example); plan the length of the review period by the amount of material to be covered, not by the clock.

2. Plan the work to be done.

  • Select one subject at a time for review, and establish and follow a sequence for review of each subject.
    (1) Answer the practice questions following the outline of the selected subject area. (Set a time limit, because pacing is important.)
    (2) Compare your answers with those provided following the questions as a means of evaluating areas of competence.
  • Identify those subjects that will require additional concentrated study in this review book as well as in basic textbooks.
  • Study the review text outlines, noting headings, subheadings, and italics and boldface type for emphasis of relative importance.
  • Study the content presented in the shaded boxes and chart format to facilitate memorization, understanding, and application.
  • Repeat the self-evaluation process by taking the test again.
  • Look up the answers for the correct response to the multiple-choice questions. Do not memorize the answers. Read the rationale explaining why it was the correct response. (These explanations serve to correct as well as reinforce. Understanding the underlying principles also serves as an aid in applying the same principles to questions that may be based on similar rationales, but phrased differently on the actual examination.)
  • If necessary, refer to basic textbooks to relearn any unclear aspects of anatomy, physiology, nutrition, or basic nursing procedures. Look up unfamiliar terminology in a medical dictionary.

While Reviewing

1. Scan the outline for main ideas and topics.

  • Do not try to remember verbatim what is on each page.
  • Paraphrase or explain this material to another person.

2. Refer to basic textbooks for details and illustrations as necessary to recall specific information related to basic sciences.

3. Integrate reading with experience.

  • Think of examples that illustrate the key concepts and principles.

After Reviewing

1. Repeat the self-evaluation process as often as necessary to gain mastery of content essential to safe nursing practice.

2. Continue to refer to major textbooks to fill in gaps where greater detail or in-depth comprehension is required.

3. Look for patterns in your selection of responses to the multiple-choice practice questions—identify sources of difficulty in choosing the most appropriate answers.

4. Review test-taking strategies.



Orientation: Key Points to Recall for Better Study

Focus topic: Orientation

1. Schedule—study time should be scheduled so that review begins close to the time at which it will be used. Retention is much better following a well-spaced review. It may be helpful to group material into small learning segments. Study goals should be set before beginning each period of study (number of pages, for example).

2. Organize—many students have better retention of material after they have reorganized and relearned it.

3. Rephrase and explain—try to rephrase material in your own words or explain it to another person. Reinforce learning through repetition and usage.

4. Decide on order of importance—organize study time in terms of importance and familiarity.

5. Use mechanical memory aids—mnemonic (memory) devices simplify recall. For example, in “On Old Olympus’s Towering Top a Finn and German Viewed Some Hops,” the first letter of each word identifies the first letter of a cranial nerve.

6. Association—associate new material with related concepts and principles from past experience.

7. Original learning—if an unfamiliar topic is presented, do more than review. Seek out sources of additional information.

8. Make notes—look for key words, phrases, and sentences in the outlined review material, and mark them for later reference.

9. Definitions—look up unfamiliar terms in a dictionary or the glossary of a basic text, or in Appendix C.

10. Additional study—refer to other textbook references for more detailed information.

11. Distractors—keep a pad of paper on hand to jot down extraneous thoughts; get them out of your mind and onto the paper.

 Orientation: Memorization: Purpose and Strategies

Focus topic: Orientation

You will need to memorize some items before you can rapidly assess or apply that knowledge to a particular situation; for example, you need to be able to recall the standard and lethal doses of a drug before deciding to administer it. Items you should memorize include, but are not limited to:

1. Names of common drugs.

2. Lethal and therapeutic doses.

3. Laboratory norms and values.

4. Growth and development norms.

5. Foods high or low in iron, protein, sodium, potassium, or carbohydrates.

6. Conversion formulas.

7. Anatomical names.

8. List of cranial nerves and their innervations.

9. Definitions of defense mechanisms.

To facilitate memorizing these and other essentials, here are some strategies:

1. Before you work on training your mind to remember, you must want to remember the material.

2. You cannot memorize something that you do not understand; therefore, know your material.

3. Visualize what you want to memorize; picture it; draw a picture.

4. Use the familiar to provide vivid mental pictures, to peg the unfamiliar.

  • When needing to remember a sequence, use your body to turn material into a picture. Draw a person, then list the first item to be memorized on top of the head, the next item on the forehead, and so on for nose, mouth, neck, chest, abdomen, thighs, knees, and feet.
  • Use what you already know to tie in with what you want to remember; make it memorable.
  • Use as pegs the unexpected, the exaggerated. Weird imagery is easiest to recall.

5. Use the blank-paper technique:

  • Place a large blank sheet on the wall.
  • After you have studied, draw on the blank paper what you remember.
  • When you have drawn all that you can recall, check with the book and study what you did correctly and incorrectly.
  • Take another sheet and do it again. Purpose: to reinforce what you already know and work with what you want to remember.

6. Make up and use mnemonic devices to help you remember the important elements

7. Repetitively explain to another person the material you want to memorize.

8. Saturate your environment with the material you want to memorize.

  • Purpose: to overcome the mind’s tendency to ignore.
  • Tape facts, formulas, concepts on walls.

9. Above all, feel confident in your ability to memorize!

 Orientation: How to Prepare for and Score Higher on Examinations

Focus topic: Orientation

The Psychology of Test-Taking

Many nursing students know the nursing material on which they are being tested, and can demonstrate their nursing skills in practice, but do not know how to prepare themselves for taking and passing examinations.
It is not just a matter of taking examinations but of knowing how to take them, taking steps to ensure you can function at full capacity, and using the allotted time in the most productive way. You must learn to use strategy and judgment in answering questions, and to make educated guesses when you are not sure of the right answer.
This section offers practical suggestions to help ensure that you are “at your best” on examination day, and discusses practical strategies for eliminating wrong answers and for increasing your chances of selecting the best ones.

Prepare Physically and Mentally

1. On the morning of an examination, avoid excessive oral intake of products that act as diuretics for you. If you know that coffee or cigarettes, for example, increase urgency and frequency, it is best to limit their intake. Undue physiological discomforts can distract your focus from the examination at hand.

2. Increase your oral intake of foods high in glucose and protein. These foods reportedly have been helpful to some examinees for keeping up their blood-sugar level. This may enhance your concentration and problem-solving ability at the times when you most need to function at a high level. On the other hand, avoid carbohydrates such as doughnuts, which slow down thinking.

3. Before examination days, avoid eating exotic or highly seasoned foods to which your system may not be accustomed. Avoid possible gastrointestinal distress when you least need it!

4. Use hard candy or something similar prior to entering the examination room, to help relieve the discomfort of a dry mouth related to a state of anxiety.

5. Wear comfortable clothes that you have worn before. The day of an examination is not a good time to wear new footwear or clothes that may prove to be constricting, binding, or uncomfortable, especially at the waistline and shoulder seams.

6. Anxiety states can bring about rapid increases and decreases in body temperature. Wear clothing that can be shed or added on. For example, you might bring a sweater that can be put on when you feel chilled or removed when your body temperature fluctuates again.

7. Women need to be prepared for late, irregular, or unanticipated early onset of menses on examination day, a time of stress.

8. Examination jitters can elicit anxiety-like reactions, both physiological and emotional. Because anxiety tends to be contagious, try to limit your contacts with those who are also experiencing examination-related anxiety or who elicit those feelings in you.

9. The night before an examination is a good time to engage in a pleasurable activity as a means of anxiety reduction. You need stamina and endurance for sitting, thinking, and reacting. Give yourself a chance for restful, not energy- or emotion-draining, activities in the days before an examination.

10. Try a relaxation process if anxiety reaches an uncomfortable level that cannot be channeled into the service of learning.

11. When you arrive home after an examination, jot down content areas that were unfamiliar to you. This may serve as a key focus for review.

 Orientation: Tips for NCLEX-RN®

Focus topic: Orientation

1. Get an early start on the day you take the examination, to avoid raising your anxiety level before the actual examination starts. Allow yourself time for delays in traffic and in public transportation or for finding a parking place. Even allow for a dead battery, flooded engine, flat tire, or bus breakdown. If you are unfamiliar with the area in which the test center is located, find it the day before.

2. Remember that you do not need to get all the answers right to pass. The examination is designed to test for minimum competence; demonstrating a higher level will not earn a special designation on your license, or any other bonus. Moreover, due to the adaptive nature of the test, you will probably reach a level where you are answering only 50% of the questions correctly; this is normal for this test and should not in itself be taken as an indication of poor performance (you may be answering 50% of the very difficult questions correctly)!

3. Because you cannot skip questions and go back to them, or go back to change answers, it is important that you simply do the best you can on a particular question and move on. The adaptive test will give you another chance to show your competence, should you get that question wrong.

4. Remember that, although you cannot change answers you have already “confirmed,” you may change your answer during the selection process. As you make your answer selection, you will choose an answer (by pressing the enter key once) and then confirm it (by pressing the <NEXT> key); you will be able to change your mind before confirming your answer choice.

5. Although the examination uses different levels of difficulty to estimate your competence level, do not try to figure out the difficulty level of each question; likewise, do not try to keep track of the number of questions you are answering. You will only distract yourself and raise your anxiety. Again, simply answer each question to the best of your ability and move on.

6. When taking practice questions, it is a good idea to aim for an average of 1 minute per question, so that you will be at a speed to finish the examination even if you do need to take the maximum number of questions. For the actual examination, however, the 6-hour time limit is not a problem for most candidates, so go ahead and take the time to work through a difficult problem, and make use of the scratch paper provided (but don’t dwell on a question you “just can’t get!”).

 Orientation: Tips for Other (Pencil-and-Paper) Tests and Examinations

Focus topic: Orientation

1. Answer the easy questions first. Too often students focus on 1 question for 10 minutes; for example, instead of going on to answer 20 additional questions during this time. The main goal in this type of examination is to answer correctly as many questions as possible.

2. Your first hunch is usually a good one. Pay attention to your intuition, which may indicate which answer “feels” best.

3. Be wise about the timing. Divide your time. For example, if you have 90 questions and 11/2 hours for the test, aim for an average of 1 question per minute. Keep working! Do not lose time looking back at your answers.

4. If you cannot decide between two multiple-choice answers, make a note of the numbers of the two choices. This will narrow down your focus when you come back to this question. Leave the question; do not spend much time on those in doubt. When you have completed the test, go back and spend more time on those with which you had trouble.

5. Exercise care and caution when using electronically scored answer sheets or booklets. It is essential that you use only the type of pencil or ink specified in the instructions. If erasing is possible, be sure to erase completely; a mere trace might throw out the answer.

6. When using a separate answer sheet or booklet, be especially careful to mark your answer in the space for the correct question number. It might be helpful to say to yourself as you answer each question, “Choice No. 4 to question No. 3,” to make sure that the right answer goes with each question number.

7. Stay the entire time allotted. If you complete the test early, check your answers. On a second look, after you have completed the test, you may find something that you are now sure you marked in error the first time. If you were undecided between two possible answers on any questions, use leftover time to reconsider those answers. (Also, look for and erase stray marks, if using electronically scored answer sheets.)

 Orientation: How to Reduce Anxiety

Focus topic: Orientation

Most people have untapped inner resources for achieving relaxation and tension release in stressful situations (such as during an examination) when they need to function at their highest potential. The goal of this discussion is to help you experience a self-guided approach to reducing your anxiety level to one that is compatible with learning and high performance.

In anxiety-producing settings whenever you feel overwhelmed or blocked, a fantasy experience can be of help in mastering the rising anxiety by promoting a feeling of calm, detached awareness, and a sense of deeper personal coping resources. Through the fantasy you can gain access to a zone of tranquility in the center of your being. Guided imagery often carries with it feelings of serenity, warmth, and comfort.

Fantasy experiences are, of course, highly individual. Techniques that help one person experience serenity may frustrate another. Try out the self-guided experiences suggested here, make up your own, and select ones that are best for you. There are endless possibilities for fantasy journeys. The best approach is to work with whatever fantasy occurs to you at the moment. The ideas for a journey presented here are meant to be a springboard for variations of your own.

A fantasy will be more effective if you take as comfortable a physical position as possible, with eyes closed and attention focused on the inner experience. Get in touch with physical sensations, your pattern and rate of breathing, your heartbeat, and pressure points of your body as it comes in contact with the chair and floor.

When you take a fantasy journey by yourself, it is important for you to read over the instructions several times so that you will be able to recall the overall structure of the fantasy. Then, close your eyes and take your trip without concern for following the instructions in detail.

 Orientation: Progressive Relaxation

Focus topic: Orientation

Relaxation approaches are used in a variety of anxiety states whenever stress interferes with the ability to function. Progressive relaxation training was originated in 1929 by Dr. Edmund Jacobson. It is a technique for attaining self-control over skeletal muscles in order to induce low-level tonus in the major muscle groups. The approach involves learning systematically and sequentially to tense and relax various muscle groups throughout the body.

The objectives of this approach are to soothe nerves, combat hypertonus in muscles, and substitute relaxing activities for stressful ones in order to feel comfortable in and more alert to the internal and external environments.

The theory behind this method takes as its basis the idea that muscular relaxation and anxiety states produce directly opposite physiological effects and thus cannot coexist. In other words, it is not possible to be tense in any body part that is completely relaxed.

The physiological changes during relaxation include decreased oxygen consumption, decreased carbon dioxide elimination, and decreased respiratory rate.

The basic factors vital to eliciting a relaxation response include the following:

1. Quiet setting—eliminate unnecessary internal and external stimuli.

2. Passive, “let-it-happen” attitude—empty your mind of thoughts and distractions.

3. Comfortable position—sit or recline in one position for 20 minutes or so.

4. Constant stimulus on which to focus—a repetitive sound, constant gaze on an object or image, or attention to one’s own breathing pattern.

Relaxation training is a procedure that can be defined, specified, and memorized until you can go through the exercises mechanically. If you regularly practice relaxation, you will be able to cope more effectively with difficult situations by reaping the physiological and psychological benefits of a balanced and relaxed state.

 Orientation: Instructions

Focus topic: Orientation

  • Sit comfortably in a chair. Shut your eyes and chase your thoughts for a minute; go where your thoughts go.
  • Then, let the words go. Become aware of how you feel, here and now, not how you would like to feel.
  • Shift your awareness to your feet. Do not move them. Become aware of what they are doing.
  • Spend 20 to 30 seconds focusing progressively on different parts of your body. Relax each part in turn:

Relax each of your toes; the tops of your feet; the arch of each foot; the insteps, balls, and heels; and your ankles, calves, knees, thighs, and buttocks. Become aware of how your body is contacting the chair in which you are sitting. Let go of your abdominal and chest muscles; relax your back. Release the tension in your shoulders, arms, elbows, forearms, wrists, hands, and each finger in turn; relax the muscles in your throat, lips, and cheeks. Wrinkle your nose; relax your eyelids and eyebrows (first one and then the other); relax the muscles in your forehead and top and back of your head. Relax your whole body.

Concentrate on your breathing; become aware of how you breathe. Allow yourself to inhale and exhale in your usual way. Become aware of the depth of your breathing. Are you expanding the lungs all the way? Or is your breathing shallow? Increase your depth of breathing. Now focus on the rate at which you are breathing. See if you can slow the rate down. When you breathe in, can you feel an inflow of energy that fills your entire body?

  • Now concentrate on the sounds in the room.
  • Focus on how you feel right now.
  • Slowly open your eyes.

 Orientation: Suggestions for Additional Experiential Vignettes

Focus topic: Orientation

  • Imagine yourself leaving the room. In your mind’s eye, go through the city and over the fields. Come to a meadow covered with fresh, new grass and flowers. Look out on the meadow and focus on what you see, hear, smell, and feel. Walk through the meadow. See the length and greenness of the grass; see the brilliance and feel the warmth of the sunlight.
  • For a more expansive feeling, visualize a mountain in the distance. Fantasize going to the country and slowly ascending a mountain. Walk through a forest. Climb to the top until at last you reach a height where you can see forever. Experience your awareness.
  • Focus on a memory of a beautiful place you have been to, enjoyed, and would like to enjoy again. Be there; experience it.
  • Imagine that you are floating on your back down a river. It may help at first to breathe deeply and feel yourself sinking. Visualize that you are coming out on a gentle river that is slowly winding its way through a beautiful forest. The sun is out and the rays feel warm on your skin. You pass trees and meadows of beautiful flowers. Smell the grass and flowers. Hear the birds. Look up in the blue sky; see the lazy tufts of clouds floating by. Leave the river and walk across the meadow. Enjoy the grass around your ankles. Come to a large tree . . .

Fill in the rest of the trip—what do you see now? Where do you want to go from here?
Sally L. Lagerquist




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