Critical Thinking
Strategies for Test Taking
• NCLEX questions are not about
recognizing facts.
• You must be able to correctly identify what
the question is asking.
• Do not focus on background information
that is not needed to answer the question.
• The NCLEX focuses on thinking through a
problem or situation.
Critical Thinking For Nurses
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Observation
Deciding what is important
Looking for pattern & relationships
Identifying the problem
Transferring knowledge from one situation to
another
• Discriminating between possible courses of
action
• Evaluation according to established criteria
• There are some strategies that you MUST
follow on EVERY NCLEX type test.
• You must ALWAYS figure out what the
question is asking.
• You must ALWAYS eliminate answer
choices.
• Choosing the best answer often involves
choosing the best of several answers that
have correct information.
• This may entail your correct analysis and
interpretation of what the question is really
asking.
• Let’s talk about how to figure out what the
question is really asking.
Reword the Question
• The first step to correctly answering
NCLEX questions is to find out what each
question is really asking.
• Step 1 – Read each question carefully
from the first word to the last word. Do not
skim over the words or read them too
quickly.
• Step 2 – Look for hints in the wording of
the question stem. The adjectives most,
first, best and initial indicate that you must
establish priorities.
• The phrase further teaching is necessary
indicates that the answer will contain
incorrect information.
• Step 3 – Reword the question stem in your
own words so that it can be answered with
a “yes” or “no”, or with a specific bit of
information.
• Step 4 – If you cannot complete step 3,
read the answer choices for clues.
What if you are “clueless”?
• No matter how well you prepare for an
NCLEX type test, there may be topics you
see on your test with which you are
unfamiliar.
• Reading the answer choices for clues will
increase your chances of selecting a
correct answer.
• You just have to calm down to access this
knowledge.
Read this Question
• A 54 year old man is being treated for
Addison’s disease. The physician orders
cortisone 25mg po daily. The nurse should
explain to the patient that adjustment of
the dosage may be required for which of
the following situations?
• 1) Dosage is increased when blood
glucose level increases.
• 2) Dosage is decreased when dietary
intake is increased.
• 3) Dosage is decreased when infection
stimulates endogenous steroid secretion.
• 4) Dosage is increased relative to an
increase in the level of stress.
Huh?
• Not sure what Addison’s disease is?
• Not sure how to adjust the dose of
cortisone?
• Step 1 – Read the question once. Resist
the impulse to reread the question.
• Step 2 – Read the answer choices. What
should you be thinking? The question
concerns cortisone.
• If the patient is receiving cortisone,
Addison’s disease must be something that
requires cortisone, a hormone from the
adrenal glands.
• You notice that dosages are both
increased and decreased.
• Step 3 – Use these clues to find the
answer to the REWORDED question,
• “What is true about adjusting cortisone
dosage?”
• 1) Dosage is increased when the blood
glucose level increases. Is this true about
cortisone?
• No, this sounds like insulin. Eliminate.
• 2) Dosage is decreased when dietary
intake is increased. Is this true about
cortisone?
• No, cortisone requirements are not related
to diet. Eliminate.
• 3) Dosage is decreased when infection
stimulates endogenous steroid secretion.
“Endogenous” means “within the patient”
If the patient is receiving cortisone for
Addison’s disease, he must have adrenal
insufficiency. Therefore, infection can’t
stimulate steroid secretion. Eliminate.
• 4) The last answer is the correct one since
it is the only one remaining. Even if you
are not confident that cortisone is
increased during periods of stress, you
can conclude that this is the correct
answer because the other choices have
been eliminated.
Another Example…
• Which of the following would most concern
the nurse during a patient’s recovery from
surgery?
• 1) Safety
• 2) Hemorrhage
• 3) Infection
• 4) Pain control
• Instructor: “The correct answer is (2).”
• Student: “Why isn’t infection the correct
answer? It says right here [pointing to the
textbook] that infection is a major
complication after surgery.”
• Instructor: “Yes, infection is an important
concern after surgery. But, if the patient has a
life threatening hemorrhage, then the fact that
the wound is infected is immaterial.”
• Student: “But it says here on page 106 that
infection is a major complication after surgery!
You can’t count this answer wrong!”
• In some situations, the faculty member will
give you partial credit for your answer or
will “throw the question out” because there
is more than one right answer.
• You won’t get the opportunity to argue
about questions on your NCLEX licensure
examination.
• The NCLEX test makers don’t throw
questions out because you don’t like them.
• You either select the answer they are
looking for or you get the question wrong.
• In the previous question, all of the answers
listed are important in caring for a
postoperative patient, but only one answer
is the best.
Another Example
• The mother of a 10 year old boy with IDDM calls
the physician’s office to discuss the child’s self
monitoring blood glucose home reading.
• He is being tightly regulated with a combination
of NPH and regular insulin before breakfast and
supper. The past two mornings his BG readings
were 220 mg/dL and 210 mg/dL. The nurse
should advise the mother to:
• 1) Continue with his medication regimen.
• 2) Check his blood sugar during the night.
• 3) Give his NPH insulin later in the
evening.
• 4) serve his bedtime snack earlier in the
evening.
Reworded Question…
• “What advice should the nurse give the
mother about her diabetic child who is
hyperglycemic in the morning?”
• Step 1 – Read the answer choices to
establish a pattern. There is one
assessment answer (2) and three
implementation answers (1), (3), and (4).
• Step 2 – Refer to the question to determine if
you should be assessing or implementing.
• The child’s mother tells you that the blood
sugars have been elevated the last two
mornings. This indicates there is a problem.
• According to the nursing process, you should
assess first. Eliminate options 1,3, and 4.
• The correct answer is (2).
• This question is about the Somogyi effect,
which is rebound hyperglycemia that
occurs in response to a rapid decrease in
the blood sugar at night.
• Treatment includes adjusting the evening
diet, changing the insulin dose, and
altering the amount of exercise to prevent
nocturnal hypoglycemia.
• Even if you have never heard of the
Somogyi effect, you are still able to
correctly answer this question using the
assessment vs Implementation strategy.
Another Example…
• The nurse is caring for a 45 year old client
who had a thyroidectomy 12 hours ago for
the treatment of Graves Disease. The
nurse would be MOST concerned if which
of the following were observed?
• 1) BP 138/82, pulse 84, respirations 16,
oral temp 99F
• 2) The patient supports his head and neck
when turning his head to the right.
• 3) The client spontaneously flexes his
wrist when the BP is obtained.
• 4) The client is drowsy and complains of a
sore throat.
Reworded Question
• What is a complication after a
thyroidectomy?
• Strategy: “MOST concerned” indicates a
complication.
• The correct answer is (3) because carpal
spasms indicate hypocalcemia (decreased
calcium from parathyroid involvement).
Another Example……
• A 26 year old man comes to the emergency
room with complaints of nausea, vomiting, and
abdominal pain. He is a type 1 diabetic. Four
days earlier, he reduced his insulin dose when
flu symptoms prevented him from eating. The
RN performs a pt assessment which reveals
poor skin turgor, dry mucous membranes, and
fruity breath odor. The nurse should be alert for
which of the following problems?
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1) Hypoglycemia
2) Viral Illness
3) Ketoacidosis
4) Hyperglycemic hyperosmolar nonketotic
coma
Reworded Question
• What do these symptoms indicate?
• (3) is the correct answer.
Another Example…
• The nurse assesses a patient with a
history of Addison’s disease who has
received steroid therapy for several years.
The nurse could expect the patient to
exhibit which of the following changes in
appearance?
• 1) Buffalo hump, girdle obesity, gaunt
facial appearance.
• 2) Tanning of the skin, discoloration of the
mucous membranes, alopecia, wt loss.
• 3) Emaciation, nervousness, breast
engorgement, hirsutism.
• 4) Truncal obesity, purple striations of the
skin, moon face.
Reworded Question
• What changes are seen in a patient after
taking steroids on a long term basis?
• Strategy: All of the options in an answer
choice must be correct for the option to be
right.
• (4) is the only response where all of the
components are correct.
Another Example…
• A patient receives 10 units of NPH insulin
every morning at 8am. At 4pm the nurse
observes that the patient is diaphoretic
and slightly confused. The FIRST action
the nurse should take is to:
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1) Check vital signs
2) check urine for glucose and ketones
3) give 6 oz of skim milk
Call the physician
Reworded Question
• What is the cause of these symptoms and
what is the FIRST thing you should do?
• The correct answer is (3): These are S&S
of hypoglycemia – give fast acting sugar
and protein & recheck BG in 15 minutes.
And Finally……
• The nurse evaluates the care provided to
a 42 year old man hospitalized for
treatment of adrenal crisis. Which of the
following changes would indicate to the
nurse that the patient is responding
favorably to medical and nursing
treatment.
• 1) The patient’s urinary output has
increased.
• 2) The patient’s blood pressure has
increased.
• 3) The patient has lost weight.
• 4) The patient’s peripheral edema has
decreased.
Reworded Question
• What shows a positive response to
treatment for adrenal crisis?
• You must know the S&S of adrenal crisis:
hypotension, cool pale skin, increased
urinary output, dehydration.
• The correct answer is (2).
• Why?
One more……..
• After teaching the mother of a young child
with a peritoneal catheter about the signs
& symptoms of peritonitis, the nurse
determines that the mother has
understood the teaching when she
identifies which of the following as an
important sign?
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1) Cloudy dialysate drainage return.
2) Distended abdomen.
3) Shortness of breath.
4) Weight gain of 3 pounds in 2 days.
Reworded Question
• Peritonitis is an INFECTION of the
peritoneal cavity. Which symptom is
consistent with an infectious process?
• Abdominal distention, weight gain, and
shortness of breath are associated with
fluid excess – not infection.
• The correct answer is (1).
• Normally, dialysate drainage return should
be clear. With peritonitis, large numbers of
bacteria, white blood cells, and fibrin
cause the dialysate to appear cloudy.
What Did We Learn Today?
• Answer what the question is asking.
• All answers may sound good but you are
going to have to select THE BEST ONE.
• Even if you don’t know the particular
subject matter, you can still extract the
correct answer.