May signifies everything we look forward to–time for graduations, pinning ceremonies, vacations, and anticipation for warmer weather; however, for the recent nursing graduate, May also signifies a time for preparation for one of the most important exams they may ever take, NCLEX. Graduates can look forward to taking the NCLEX if they remember PUPS. (More on PUPS below).
As nurse educators, we know that prepping for NCLEX differs from preparing for a classroom exam. For one, the NCLEX is a cumulative exam that focuses on one thing, clinical judgment. Can the student make the best decision for their patient at the bedside?
Secondly, the NCLEX tests integrate processes like safety, infection control, and physiological integrity throughout the test. It’s not divided into pharmacology, pediatrics, and management like nursing school courses and tests. It is a comprehensive evaluation of the nursing graduate’s ability to holistically care for a patient, from basic care and comfort to management of other healthcare staff.
Because of this comprehensive and integrated approach, questions may look different and be perceived as more difficult. Medications and disease processes the student did not learn in class may be tested. For most students, the unknown is a scary concept. However, there are things we can do, even last minute, to prepare our students.
Remember PUPS. If you’re like most nurses, we care for humans and animals. Hopefully, PUPS is an easy to remember mnemonic and one with a positive connotation.
Practice NCLEX-style questions
Understand the NCLEX
Practice anti-anxiety techniques
Show up prepared
Practice NCLEX- style Questions
There are studies and literature that state a student must answer 5000 to 10,000 questions to be deemed ready for NCLEX. There are hundreds of websites that students frequent that provide many different numbers. I have seen very specific numbers, from 2800 questions to as low as 500. Quantity matters, but quality matters more. We must inform our students that practicing NCLEX-like questions is critical to success and where they can find those questions. Please provide them with the names of credible resources and encourage them to practice as many questions as possible.
Practice means answering the questions and remediating them to understand what they do and don’t know. Practice does not mean answering question after question but never reviewing the answers and rationales. The question banks students use for preparation should include an opportunity for testing in an NCLEX-like environment and provide a review of answers with rationales. The practice question banks should also have alternate-type questions on NCLEX and be written at the cognitive levels of application and analysis. Practice means simulating the real testing environment by sitting in a quiet room and answering the questions on the computer while you time yourself. The NCLEX today is 75-145 questions with a five-hour allotment. Encourage your students to take a 75-question minimum test and to take several 145-question tests as well. Practicing a few questions at a time is okay but should be only some of the practice.
Endurance is important. Most students graduate from nursing school and have never taken more than 100 questions at one time. However, they must practice a 145-question test and note when they get tired or lose concentration to take a break in the “real” test. Therefore, a student should never sit for NCLEX without having the benefit of practicing 145-question tests.
Understand the NCLEX
All students taking the NCLEX should have visited the website ncsbn.org many times. They should know the NCLEX blueprint–the definitions of the client need categories tested and at what percentage they are tested. Students want to know what is on the test to feel more comfortable and confident. The NCSBN gives them that information. Maybe not to the specificity the student wants, but it provides much beneficial information, and knowledge is power.
For example, a student must know that physiological adaptation, management of care, and pharmacological and parenteral therapies make up almost 50% of the NCLEX-RN. Therefore, these three areas command more attention than the other five areas of the test plan.
Students should also watch the videos on the ncsbn.org website that explain the testing procedures for check-in and while taking the test. These videos include what you can and cannot bring with you, allowable breaks, accommodation requests, and much more. Knowing what to expect lessens anxiety.
Practice Anti-anxiety Techniques
As mentioned above, one of the reasons students practice questions is to understand their mental and physical endurance. Students should note when they get tired or lose focus while taking a long exam. For some students, that’s around 50 questions. For others, it’s about ten questions. Students need to know this before sitting for NCLEX. When they reach their limit, instruct them to take a mental break. That could mean taking fingers off the keyboard and eyes off the screen, completing a few stretches of the shoulders and neck, or taking a few deep breaths.
A quick note about deep breathing: it’s not just something to do. Deep breathing better oxygenates your brain, stimulating the parasympathetic nervous system, which aids in calmness. Deep breathing is an important anti-anxiety strategy for us all.
Other techniques to combat anxiety include getting adequate sleep (which is especially important the night before the test); eating a good meal before the test so that you are not hungry (do not overdo it on carbs or sugar, which can cause sleepiness); proper hydration preferably with water and a bathroom break before the exam; positive talk before and during the exam (You got this!); eating peppermint candy or chewing peppermint gum which can decrease anxiety and possibly increase mental alertness (I’ve had several students who swear by peppermint); and the most crucial technique to combat anxiety, is tip #4–show up prepared.
Show Up Prepared
There is no better technique for success than attending an exam and feeling well-prepared. Know where the testing center is and leave early to give yourself plenty of time for unexpected traffic. Students should double-check with ncsbn.org that they have the correct documents to get into the test.
At this point in their preparation, they know the content, the process, and what to expect. There are no surprises because they have used PUPS – practiced thousands of questions, understand how the test works and what is being tested, know how to calm anxiety because they have practiced calming techniques, and are showing up prepared and confident.
Hanson-Zalot, M. , Gerolamo, A. and Ward, J. (2019) The Voices of Graduates: Informing Faculty Practices to Establish Best Practices for Readying NCLEX-RN Applicants. Open Journal of Nursing, 9, 125-136. doi: 10.4236/ojn.2019.92012.
The National Council Licensure Examination is a prerequisite for becoming a nurse, and with increased nursing school applicants, we thought it would be worthwhile to offer tips on how best to pass the NCLEX. We each tried our techniques and utilized similar options to help us pass the exam in May of this year. With some guidance from our parents, we also have plenty of tips to help others pass this challenging exam with much more confidence than you otherwise might have exhibited.
Watch Tips and Tutorials on YouTube
YouTube has tons of great material on every subject, including the NCLEX. We recommend finding some tutorials and tips to help you pass. Shannon, in particular, used this study method for subjects she didn’t fully understand. It enables you to gain knowledge in areas where you’re lacking and is just a fun, easy way to gain more information and help you feel more confident with that material.
Allot Yourself So Many NCLEX Questions Per Day
Don’t try to push yourself to get through hundreds of practice questions when you don’t have the mental capacity. Instead, give yourself a few months to take your time and practice until you feel comfortable. It’s best to allot yourself so many questions daily and only focus on getting through one set at a time. Shannon stuck with the 75 questions per day rule, and it helped.
You can also go with Kristyn’s technique and allot yourself so many daily topics. Then, pick two or three and work on the material until you feel like you’ve nailed it. She spent one month working this way until she felt confident she could pass the test.
Study and Correct Your Incorrect Answers
By only focusing on so many questions each day, you have time to go back over the answers. You can correct anything you got wrong and take the time to understand why it was wrong. Then, use your results to help you study better and refocus on the problems you’re having trouble tackling.
Let Your Family Help
You don’t have to do this alone. Sure, you’ll be the only one taking the test, but that doesn’t mean you can’t get help practicing and preparing in the meantime. Let your family help you in any way they can—we both did. Kristyn’s mom helped her by being a pretend patient. Her aunt and uncle let her stay with them while in college to help save on costs. Shannon’s dad tried to help keep their dog occupied, so he wasn’t in her way or disturbing her studies.
Be Sure to Eat Healthily
Speaking of Shannon’s dad, Mark stresses the importance of eating well. It’s important to eat something healthy and keep your body full and your brain working to the best of its ability while studying and before you have a big exam. So, eat something healthy and keep your body full and your brain working to the best of its ability. That will go a long way toward ensuring you can pass your NCLEX without the pangs of hunger interrupting your thought process.
Also, Enjoy a Snack
You don’t have to eat all the time healthily, however. Sometimes, it’s good to get your favorite snack and reward yourself a little for the hard work you’ve been doing. So, grab your favorite candy bar and savor every bite before you get back to the work at hand. That little bit of goodness in your day can be a huge motivator and help when feeling down.
Add Vitamin D to Your Day
It’s also essential to make sure you’re staying healthy overall. Adding Vitamin D to your day, especially by soaking it up outside, is beneficial for how you feel mentally. Don’t just sit and study for the entire day. Get outside. Enjoy the fresh air. Take the break you need and deserve. It will help give you mental clarity so you can return to your study routine afterward.
Utilize UWorld
One of the best things you can do for yourself (or a family member) is to purchase a pretest system that allows you to see how well you would do on your NCLEX. It’s excellent practice and shows you the areas where you need additional guidance before you take the actual test. We used UWorld, and it offers options for both RNs and PNs. It helped us gain the information and experience necessary to help us feel genuinely prepared for the exam in real life. In addition, the UWorld NCLEX-RNⓇ provides more than 2,000 questions to help prepare for your impending. If you want easy-to-understand information, this program is for you.
Take Your Time During the NCLEX
Our final piece of advice is to take your time. It isn’t necessary to feel rushed during the NCLEX because you get five total hours for the entirety of it. Don’t rush through any questions. Please read it thoroughly so that you’re entirely comprehending what it’s asking. Some questions can be tricky, and you’ll misinterpret what it’s asking for if you don’t read them all the way through and give yourself time to sort through the possible answers.
Why Preparing to Be a Nurse Is So Important
It takes a village to support nursing students and current nurses, particularly given the added stress of the pandemic. In addition, as current nurses are exiting the profession due to burnout or attrition in large numbers, student nurses must find the resources they need to support their academic and career goals. A family and friends support network can also help make all the difference in reaching your goal of being a nurse with a healthy work-life balance.
This article written by Shannon Rosen and Kristyn Smith was published in the September 2022 issue of Minority Nurse.
About the authors
Shannon Rosen graduated from Nova Southeastern University, passed the NCLEX in May 2022, and is an Operating Room Nurse at Naples Community Hospital in Naples, Florida.
Kristyn Smith graduated from Chamberlain University, passed the NCLEX in May 2022, and is a Pediatric ER Nurse at a hospital in Houston, Texas.
Achieving a 100% pass rate on the National Council Licensure Examination for Registered Nurses (NCLEX-RN) was a goal that seemed impossible, especially in 2021. Nursing schools were in the midst of a national pandemic and learning how to teach nursing in both face-to-face and virtual settings. If past performance rates on the NCLEX-RN were an indication of things to come, the University of West Alabama Division of Nursing (DON) could have expected a disastrous 2021 year. In 2013, the program’s NCLEX-RN pass rate fell to 74%. While it rebounded during 2014-2017 (82.4, 85, 88, and 81.6%, respectively), the nursing faculty realized there was a pattern in NCLEX-RN rates that directly correlated to their student population. Scores declined again in 2018 (77.3%).
Multi-Pronged Approach
A multi-pronged approach had to be used to help the UWA DON prepare its students for success, not only during a pandemic, but post-pandemic. In 2013, one nursing faculty member was enrolled in a doctor of education program, while the other six faculty held a Master’s degree in nursing. A focus on faculty development for young faculty was crucial, but faculty development in education was also beneficial to those who lacked the tools to understand curriculum development, test-item development, and test-taking strategies. Currently, six faculty members hold doctorate degrees with an emphasis in nursing education, while one is enrolled in a doctoral program. As faculty members were earning degrees, they were learning to use research practices and methodologies to understand and predict the habits of their students.
Located in the Blackbelt region of west Alabama, the University of West Alabama serves some of the poorest counties in the nation. Students come from educationally and economically disadvantaged backgrounds, adding a layer of complexity to a curriculum fraught with rigor and time constraints.
Students are expected to attend class, skills labs, simulation labs, and clinical labs Monday through Friday. For those who have to work to make ends meet, have children or older relatives to care for, or who are ill-equipped for the study and time demands of a nursing curriculum, the first and second semester of the nursing program may prove too much to endure. To determine student learning needs and implement initiatives to support progression and graduation from the nursing program, the faculty assessed the needs of the program’s student population and diagnosed the issues hindering progression, program completion, and passing the NCLEX-RN. They could then plan interventions that would lead to better student outcomes, implement the plan promptly, and evaluate the plan for areas of strength, weakness, and opportunities.
Program Assessment
Program assessment was key to the process. Students were having difficulty in the third semester of the nursing program. Retention of content appeared to be an issue for the fourth-semester nursing students. Foundational principles of basic care and comfort were troublesome, as were the dreaded multiple-answer questions, also known as “select all that apply” (SATA). Students in the first and second semesters appeared to have trouble understanding what the question was asking them to determine. It was evident that reading comprehension was an issue for some students.
For others, a review of ACT scores on file revealed students were not very good standardized test-takers and needed intentional practice to improve test-taking skills, not merely testing for content knowledge. If a student was repeating the nursing program, they were less likely to pass the NCLEX-RN exam on the first attempt than students who completed the program in five semesters. Finally, students needed help with goal-setting, time-management, and study skills that would allow them to progress and graduate on time. With this information on board, it was time to implement strategies to help the associate in science nursing students reach their full potential and successfully graduate from the nursing program while preparing them to successfully pass the national licensure exam.
The nursing program functions from a multi-tiered approach to engage students and monitor progress throughout the semester. Each approach is needed to provide a comprehensive and inclusive model to facilitate a culture of success in the nursing program.
Faculty-Student Mentoring
A faculty-student mentoring program was important to understand the academic and non-academic challenges that nursing students would face as individuals. Individualized action plans could be created for each student to assist in program progression. The faculty-student mentoring program requires all students entering the nursing program to be assigned to a faculty mentor. Students meet with their mentors two weeks into the semester and at regular intervals during the semester to monitor academic progress and discuss issues that may deter progression or strategies that will foster success.
Retention and Progression Methodologies
Once students have been admitted to the nursing program, student progression and retention become the focal point. Students enter the program with a multitude of life affairs – children, work, bills that need to be paid.
For these reasons and others, the nursing curriculum was infused with ways to integrate positive study habits, reiterate test-taking skills, and repeat information deemed “need-to-know.” While Faculty-Student Mentors introduce students to these habits and reinforce them as necessary, a Retention Specialist (RS) would be assigned to students who were at-risk of failing the nursing program due to class performance. Student grades were monitored closely and referrals were made to the RS when needed. Some students are assigned to a RS at the outset of the nursing program and are required to meet with the RS before the first exam to review the importance of class attendance, note-taking, study habits, and test-taking strategies.
The use of repetition throughout the program has proven to be very useful. Students are encouraged to use practice test items to prepare for examinations. Students are also encouraged to create peer study groups of no more than four students to study before the exam. Students need to understand that nursing content is to be learned and not memorized for test purposes only. Convincing students to change their study habits and teaching them how to study plays an important role in progression.
NCLEX-RN Preparation
Students who graduated from the nursing program were not always successful at passing their licensure examination on the first attempt. For some, a second attempt was needed. Finding a solution to prevent this second attempt was important to the nursing program due to the financial burden that it can place on graduates, and the real and perceived negative burden placed on nursing programs by accrediting bodies. The first-time pass rate continues to be a program outcome standard that nursing programs are measured by, in spite of the increased test anxiety seen in students today.
In 2019, the Division of Nursing found a game-changer to its preparation for licensure. The introduction of UWorld NCLEX-RN QBank as a means to create practice exams for the licensure exam was one of the most significant changes made in improving licensure scores. Initially, faculty implemented the prep system without a policy to guide student behavior. Minimal gains were noted. With the introduction of a formal policy on UWorld QBank, the nursing program’s graduates were able to earn a 100% first-time pass rate on the NCLEX-RN in 2021. The UWorld policy is housed in the NS 204: Advanced Adult Health and Critical Care course taken in the final semester. Students must complete a minimum of 2000 questions in the UWorld QBank and achieve a minimum score of 65% correctly answered questions. To achieve this goal, most students have to answer in excess of 3,000 questions.
In addition to prepping, students also needed to understand the time-sensitive nature of learned content and test-taking strategies. The nursing program fully believes that its graduates are prepared to care for patients as advanced beginners as bedside nurses. But there is an awareness that test-taking behaviors and learned content will begin to fade over time. As graduates begin to practice, their new behavior will replace learned behavior. The second critical step to licensure prep for our students was testing in a timely manner. Nursing graduates were encouraged to take the NCLEX-RN by June 15th, a date that generally falls six weeks post-graduation. Students have had their NCLEX-RN review, they have completed the prep question set as stated in the course syllabus, and they have completed a predictor on NCLEX performance. The six weeks give them more time to prepare if needed, but most are ready to take the exam when a test date is available.
Financial Support
In 2020, the Division of Nursing was awarded a grant through Health Resources and Services Administration (HRSA) to support students from disadvantaged backgrounds. Project EARN (Educating Alabama’s Rural Nurses), in the amount of $2.4 million, is dedicated exclusively to scholarships. Nursing programs add costs to college students with the purchase of uniforms, assessment tools, NCLEX preparation, and travel to and from clinical sites. Many UWA students are nontraditional and/or from disadvantaged backgrounds. Alleviating the financial stress of getting a college degree has allowed students to focus on studying and graduation.
For the UWA DON, a multifaceted approach to program progression and completion has always been necessary. The mystery lay in passing the NCLEX-RN on the first attempt. The addition of a prep tool for licensure has proven to be a game-changer for nursing students. As 2022 nursing students gear up for the licensure exam, the policy is in place and UWA nursing faculty are anxious to learn if they have found the key to NCLEX success for their program.
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