The final test

This morning I took the final test to determine whether I'm licensed as a registered nurse (RN). The NCLEX, as it's known, determines whether the candidate possesses the entry-level knowledge so as to "provide safe and effective nursing care." It's a computer adaptive test, which means that each succeeding question is determined by how the test-taker is performing. At the beginning of the NCLEX, the computer program gives you a medium difficulty-level question. If you get it right, the next question is more difficult. If you get it wrong, the next question is easier. The idea is to maintain your performance above a line of competency. It's okay to dip below it occasionally, but then the candidate has to answer more questions correctly to rise above the line again.

In addition to level-of-difficulty, questions are categorized by Client Needs category. Candidates have to demonstrate competency in Management of Care, Safety and Infection Control, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity. You can't crap out in one category and then make it up in another either.

Practically, the computer adaptive format means you can't skip questions and come back to them, a favorite tactic of mine. Really though, the format is not that bad. You are presented a scenario and usually have to choose between four answers. Sometimes you have to fill in the blank, but that's usually a medication calculation question with a numerical answer. The beastly questions are the ones where you must select all that apply with five options. Get one wrong and the whole question is wrong.

Here's an example of a question from a test prep book with my explanation of terms in brackets or a link to a picture:

A nurse is caring for a client with a T5 spinal cord injury. The client complains of a severe headache and is feeling anxious. The nurse notes the client is sweating, is experiencing bradycardia [pulse below 50 beats per minute], and is hypertensive [high blood pressure, exact number is situation- and client-dependent]. Which nursing intervention is most appropriate initially?

1) Notify the physician
2) Medicate with an analgesic [pain-relief]
3) Check for bladder distention
4) Discuss the client's feeling of anxiety

The correct answer is 3. To answer this question you have to know such spinal cord injuries put the patient at risk for autonomic dysreflexia, the symptoms of that condition, the likely cause, and that assessing for a distended bladder is the INITIAL action of the nurse.

This question is at the analysis level in that you have to know some facts and then apply them to the scenario. This is actually a pretty easy question for someone right out of nursing school. It's common knowledge that notifiying a doctor is almost never the right answer (there's always something to do first), and discussing feelings is always a low priority - physiologic concerns first, psychosocial later. So even if you don't remember autonomic dysreflexia, you're down to 50/50 anyway. Getting it down to two answers happens all the time. Often, two or three answers are right and it's just a question of which is more right. It's difficult at first, but nursing school tests are usually written this way so students have plenty of practice with the format.

The minimum number of questions on the NCLEX is 75 of which 15 are unscored because they're just being tried out. After 75 questions, the program reviews your performance and decides that either that you are competent, not competent, or that further assessment is necessary. If the latter, the program keeps giving you questions until the answer is decisive. The maximum number of questions is 265, though few candidates get that many. You have six hours to take the test and again, few take that long.

The first-time pass rate for students from my nursing school hovers aroung 98-100% so I wasn't too worried. Still, it was nerve-wracking to take a test that determines whether I'm allowed to practice what I've been working toward for three-and-a-half years. The general wisdom is that if the questions are somewhat confusing and nebulous, and you walk out not really knowing what the hell you were doing, you performed well. If the questions start to look like:

The brain is

1) protected by the skull
2) insane in the membrane
3) solely for mucus production
4) wait, you mean the one in my head or Big Steve downstairs?

you're in trouble. I took 80 minutes to answer 75 questions of which I definitely, no doubt about it KNEW the answers of about 10. So, good sign! I'll find out the unofficial results Monday or Tuesday. Oh and my diploma came in the mail today, so that's nice.