item writing objectives begin with the end in mind: the ... · 5/15/2018 1 begin with the end in...

5/15/2018

1

Begin with the End in Mind: The Art of Item

Writing

Janean Johnson, MSN, RN, CNE

1

ITEM WRITING OBJECTIVES

Analyze the NCLEX® detailed test plan.

Discuss the various types of items included on the

NCLEX ® exam.

Use strategies to construct NCLEX ® -style items that

assess a student’s critical thinking skills.

2

The Art and Science of Item Writing

3

START WITH THE END IN MIND

4

Evaluate student acquisition of learning outcomes

NCLEX® detailed test blueprint

There are many ways to measure the quality

of a nursing program.

It is important that our graduates pass

NCLEX®.

Acquaint students with NCLEX® style test items,

― From first nursing course throughout the program.

― Alternate format items

Components of the Test Plan

Client Need Category

Subcategory

Related Content

Task

Safe, Effective Care Environment

Management of Care (RN)

Coordinated Care (PN)

Advance Directives

Assess client and/or staff member knowledge of

advance directives

5

NCLEX Integrated Process

2017 PN

Nursing Process

― Data Collection

― Planning

― Implementation

― Evaluation

Caring

Communication &

Documentation

― Verbal / Nonverbal

― EMR/EHR

― Standards of practice

Teaching/Learning (KSA)

Culture and Spirituality

6

2016 RN

Nursing Process

― Assessment

― Analysis

― Planning

― Implementation

― Evaluation

Caring

Communication &

Documentation

― Verbal / Nonverbal

― EMR/EHR

― Standards of practice

Teaching/Learning (KSA)

Culture and Spirituality

5/15/2018

2

Developing Course Test

The information needs to be important for an entry-level, generalist nurse to know

Tool used to measure student achievement

― Evaluate student acquisition of knowledge

― Evaluate student ability to apply knowledge

The item should identify how well the student achieved the course/unit learning outcomes

Tool used to evaluate effectiveness of teaching strategies

7

TIPS FOR ITEM WRITING Ask questions

- Relevant to learning outcomes

and objectives.

- That reflect the class time used

for specific content area.

- Containing information

important for entry-level nurses

- Reflect NCLEX® test plan

- Test nursing ability

Do not confuse student about

what you are asking

Use familiar vocabulary. Test

content, not reading

comprehension.

― 10th to 12th grade reading level

Omit unnecessary text

Proofread for grammar, punctuation

and spelling.

At least 2 sets of eyes should

review every test before

administration.

Avoid culture specific words, brand

names, geographic-specific terms,

and slang (Jell-O, Legos, Kotex,

Subway, Pop/Soda/Coke etc.)

Item difficulty does not represented

in the stem, but rather in selecting

the correct response, action, or

decision

8

USING NCLEX STYLE TERMINOLOGY

9

Use Avoid

client “reports” client “complains of”

focus on the client, say client who

has…client diagnosed with

don’t label the client

only relevant information gender, age, marital status, racial references (unless

pertinent to testing point)

prescription order

provider physician, doctor, nurse practitioner, physician assistant

generic names Trade names

active present tense (e.g. “should

do”) Make it clear what the question is

Awkward /wordy sentences

A nurse; A client Personal pronouns

Use full word (hypertension) abbreviations (e.g. HTN)

Indwelling urinary catheter Foley catheter

Staying on Track

10

How can we stay focused on our purpose when writing items?

Try asking yourself….

― What is the content? And is it level appropriate?

― What is the learning outcome?

― What is the NCLEX® task?

― Is the stem clear and concise

― Are distractors plausible yet wrong?

PEER REVIEW PROCESS

Development of good test items is an ongoing process

Establish peer dyads

― Review/edit each other’s items

― Review/edit each other’s tests

― Maintain peer review dyads

Review p values (item difficulty) and point biserial (item

discrimination) of items after administration

― Use spreadsheet or 5X7 cards to monitor item statistics

― Track over time as changes are made to items

11

TELL ME MORE ABOUT NCLEX ITEM TYPES

NCLEX Item Types

― Multiple choice

― Multiple response

― Hot Spot

― Fill-in-the-blank

― Chart Exhibit

― Graphic

― Audio

― Ordered response

12

5/15/2018

3

WRITING ITEMS

STEM

• Scenario

• Question

OPTIONS

• Key

• Distractors

RATIONALES

• Rationales

13

WRITING ITEMS: STEM Must be relevant to entry-level practice

― Nurse-client interactions

― Assessment/Data collection

― Analysis

― Planning

― Interventions

― Evaluation

― Documentation

― Management of care

Avoid ― Nursing diagnosis

― Content not tested on NCLEX ®

Limit ― Medical disorders

― Pathophysiology/etiology

― Definitions/terminology

14

WRITING ITEMS: Scenario

Scenario

― Client care related situation

― Provides information that students should consider when answering item

― Usually first 1-2 sentences of the stem

― Always contains a nurse, client, and context

― Identify a step of the nursing process

No context (avoid)

― According to the Centers for Disease Control and Prevention, which of the following clients should receive the zoster immunization?

Context (include)

― A nurse is obtaining a health history from a client. Which of the following findings indicates the need for a zoster immunization?

15

Practice writing item with context

Without Context

Which of the following

actions should a nurse take

to confirm a client’s identity

when administering

medication?

Practice writing item with

context

16

With Context

A nurse is preparing to administer

medications to a client. Which of the

following actions should the nurse

take to confirm the client’s identity?

17

WRITING ITEMS: Question

The Question

― Last sentence of the stem

―Answers question related to scenario

―Asks a specific question student should know

using nursing knowledge

―Three types of questions

• Positively worded

• Negatively worded

• Priority setting

18

5/15/2018

4


Positively worded item

―Answers question with correct action

―One correct action

―Three incorrect actions

A nurse is changing the dressing for a client who is

postoperative from a colon resection. Which of the

following is an appropriate action by the nurse?

19


Negatively worded- use as few as possible

―Answers question with incorrect action

―Three correct actions

―One incorrect action

―Easy to read incorrectly; watch item stats

A nurse is changing the dressing for a client who

is postoperative from a colon resection. Which of

the following is an incorrect action by the nurse?

20


Priority setting

―Answers questions with “best” answer

―Four correct actions

―One correct option based on priority setting

framework applied to scenario

―Often asked for best, first, priority, etc.

―These words are bolded on the NCLEX®

A nurse is changing the dressing for a client who

is postoperative from a colon resection. Which of

the following actions should the nurse take first?

21

KEY WORDS

What are key words?

―Critical words or phrases in an item

― Important for students to be able to recognize these

―Key words can be in scenario and question

―Options can be developed around alternate key word

22

GROUP REVIEW – Key Words

What are the key words?

A nurse is caring for a client who is receiving bolus

tube feedings via a gastrostomy tube. Which of the

following is an appropriate action the nurse should

take when preparing to administer the feeding?

23

GROUP REVIEW – Key Words

A nurse is caring for a client who is receiving bolus

tube feedings via a gastrostomy tube. Which of the

following is an appropriate action the nurse should

take when preparing to administer the feeding?

24

5/15/2018

5

GROUP REVIEW – STEM

Revise the following stem.

A nurse is caring for a 72-year-old male cardiac client who

was admitted from the emergency department to the

medical unit 4 hr ago. The client has a history of HTN. He is

scheduled for a cardiac catheterization on the next shift

using a radiopaque dye. When checking for food allergies,

which of the following findings is the nurse’s priority?

25

GROUP REVIEW – STEM

Possible revision

A nurse is caring for a 72-year old male cardiac

client who was admitted from the emergency

department to the medical unit 4 hr ago. The client

has a history of HTN. He is scheduled for a cardiac

catheterization on the next shift using a radiopaque

dye. When checking for food allergies, which of the

following findings is the nurse’s priority?

26

WRITING ITEMS: OPTIONS Key

― Correct option

― Answers question posed in the stem

― Defensible rationale based on evidence

― Requires nursing knowledge

• Traditional multiple choice items have one key

• Multiple response items have 5-6 options;

single correct response, more than one correct response, all responses correct regardless of the number of possible responses

• Priority setting items have one key

Distractor ― “Distracts” student from correct answer

― Needs to be plausible

― Grammatically correct with stem (a/an; is/are)

27

WRITING ITEMS: OPTIONS

Positively worded stem

―Has 1 correct option

―Has 3 incorrect options




Use sterile gloves to remove the soiled dressing

Place soiled dressing in the client’s trash can

Open sterile dressings before putting on sterile gloves

Write date and time on dressing with a marker

28


Positively worded stem

―Has 1 correct option

―Has 3 incorrect options




Use sterile gloves to remove the soiled dressing

Place soiled dressing in the client’s trash can


Write date and time on dressing with a marker

29


Negatively worded

―Has 3 correct options

―Has 1 incorrect option



following is an incorrect action by the nurse?

Use clean gloves to remove the soiled dressing

Place soiled dressing in a disposable sack

Open sterile dressings after putting on sterile gloves

Write date and time on dressing with a pen

30

5/15/2018

6


Negatively worded

―Has 3 correct options

―Has 1 incorrect option



following is an incorrect action by the nurse?

Use clean gloves to remove the old dressing

Place old dressing in a disposable sack

Open sterile dressings after putting on sterile gloves


31

IS IT OVER OKAY TO WRITE

NEGATIVELY WORDED ITEMS?

Avoid writing negatively stated items as much as possible.

Exception-some NCLEX® tasks are negatively worded and require a negatively stated item.

Examples of when a negatively stated item is appropriate

- when evaluating delegated care or monitoring another nurse’s care

- when identifying contraindications, barriers, developmental delays

- when verifying prescriptions

32

EXAMPLES OF NEGATIVE TASKS

Evaluating care that another

health care provider (RN, PN,

AP)

Verify appropriateness and/or

accuracy of a treatment order

Compare client development to

expected age/developmental

stage and report any deviations

A charge nurse on a medical unit is

observing a newly licensed nurse

provide care. Which of the following

actions by the newly licensed nurse

indicates that the charge nurse should

intervene?

A nurse is assessing a client who has

bipolar disorder and is to start a new

prescription for lithium carbonate.

Which of the following findings should

indicate to the nurse the need to

assess further?

A nurse in a provider's office is

assessing an 18-month-old child.

Which of the following findings

indicates that the child has a

developmental delay? 33


Priority setting item

―Answers question with “best” answer



following is the first action the nurse should take?





34


Priority setting

―Answers question with “best” answer



following is the first action the nurse should take?





35


Do not use following as distractors:

―Notify the provider

―Notify the charge nurse

―Follow agency procedure

―Always, only, never, every

―All of the above

―None of the above

36

5/15/2018

7

GROUP REVIEW

What is the correct answer?

Why does the sigla frequently overfesk the

trelsum?

All siglas are mellious

Siglas are always votial

The trelsum is usually tarious

No trelsa are directly feskable

37


Finer points of writing good options:

―Strive for symmetry in the four options

―Avoid mutually exclusive options

―Avoid using same/similar terms in stem and key

―Don’t introduce new information

―Write options that are independent

―Avoid creating subsets

― Include no more than two “elements” per option

―Avoid options that are partially or could arguably

be correct

―Avoid having a number only in the key

38

WRITING ITEMS: Symmetry

Strive for symmetry in the four options

―Which option is the key?

STEM

Short sentence

Short sentence

Medium length sentence

Really long and wordy sentence

39



―Which option is the key?

STEM

Apple

Orange

Banana

Hammer

40



― Now which option is the key?

STEM

Apple

Orange

Wrench

Hammer

41

Avoid mutually exclusive options

WRITING ITEMS: Mutually Exclusive

A nurse is planning to change a client’s wound

dressing. Which of the following actions should

the nurse plan to take?

A. Cover the wound with a dry dressing.

B. Keep the wound open to air.

C. Irrigate the wound with povidone-iodine.

D. Apply lidocaine gel to the wound.

42

5/15/2018

8

WRITING ITEMS: Same Terms

Avoid using same/similar terms in stem & key

A nurse is caring for a client who is grieving the recent

death of her partner. Which of the following actions

should the nurse take?

A. Develop a trusting relationship by offering the client

sympathy.

B. Encourage the client to talk about the death of her

partner.

C. Remind the client that she will feel better in a few

months.

D. Tell the client about a recent loss of a loved one.

43

Don’t introduce new information

WRITING ITEMS: New Information

A nurse is providing instruction about management

of diabetes to a client. Which of the following

information should the nurse include?

A. Self-administer insulin lispro at bedtime.

B. Apply moisturizer between your toes after

bathing.

C. Eat consistent number of grams of carbohydrate

at each meal.

D. Avoid eating after strenuous exercise.

44

WRITING ITEMS: Independent

Write options that are independent

During a mass casualty drill a nurse is taking

care of a client in shock. Which of the following

intervention should the nurse take?

A. Lowering the client’s body temperature

B. Rapidly cooling the client’s skin

C. Elevating the client’s legs

D. Orally rehydrating the client

45

WRITING ITEMS: Subsets

Avoid creating subsets

A nurse is anticipating transfer of a client to the PACU.

Which of the following should the nurse check upon

the client’s arrival?

A. Vital signs

B. Blood pressure

C. Heart rate

D. Skin turgor

46

WRITING ITEMS: Two Options/

Partially Correct

No more than two elements per option

Avoid options that are partially or could arguably

be correct

The nurse is caring for a client with a suspected

myocardial infarction. Which of the following

assessments findings should the nurse expect?

A. Bradycardia, dyspnea and dizziness

B. Tachycardia, dyspnea and palpitations

C. Nausea, vomiting and warm, dry skin

D. Dyspnea, dizziness and hyperactivity

47

WRITING ITEMS: Two Options/

Partially Correct

No more than two elements per option

Avoid options that are partially or could arguably

be correct

A nurse is assessing a client who experiencing

a myocardial infarction. Which of the following

findings should the nurse expect?

Bradycardia, dyspnea and dizziness

Tachycardia, dyspnea and palpitations

Nausea, vomiting and warm, dry skin

Dyspnea, dizziness and hyperactivity

48

5/15/2018

9


Avoid having a number only in the key

― If numbers are in any option, then put 2 numbers in at least 2

options

― If numbers are in 3 options, the option without a number can’t

be the key

A nurse is providing discharge instruction to a client who is

postoperative from a cataract extraction. Which of the following

instructions should the nurse include?

A. Bend at the waist to pick up an object from the floor.

B. Do not lift an object that weighs more than 10 pounds.

C. Avoid wearing your eye shield to bed.

D. Lie on your operative side when resting.

49


Other pearls for writing strong options

―Keep options homogenous

• All nursing interventions, medications, lab values,

etc.

• Ascending, descending, parallel lengths

• Comparable level of technical language and

complexity

―Two pairs of opposites; only 1 pair is not acceptable

• Tachy- and Bradycardia

• Hyper- and Hypotension

50


Other pearls for writing strong options

―Vary placement of correct answers

―Place in a logical order (alphabetical, numerical,

increasing/decreasing length)

―NO multiple, multiples!!!

51

Critique following item

GROUP REVIEW – OPTIONS

A nurse is preparing to administer digoxin to a client

who has heart failure. The nurse should assess the

client for which of the following findings?

A. bradycardia, hypokalemia, and gastric upset

B. constipation, bradycardia, and hypokalemia

C. hypokalemia, dry mouth, and bradycardia

D. hypertension, bradycardia, and hypokalemia

52

Critique following item

GROUP REVIEW – OPTIONS

A nurse is preparing to administer digoxin to a client

who has heart failure. The nurse should check the

client for which of the following findings?

A. bradycardia, hypokalemia, and gastric upset

B. constipation, bradycardia, and hypokalemia

C. hypokalemia, dry mouth, and bradycardia

D. hypertension, bradycardia, and hypokalemia

53

Key

―Explain why the key is correct

Distractors

―Give brief explanation of why distractor is wrong

―Avoid

• Saying “this is not the correct option”

• Including “peripheral” information

• Giving away the key

RATIONALES

54

5/15/2018

10

RATIONALES - VAGUE

Options Rationales

Bradycardia This is not expected manifestation for a client

whose T4 is 13.5 mcg/dL.

Diarrhea This is not expected manifestation for a client


Periorbital edema This is not expected manifestation for a client


Hypertension Hypertension is an expected finding for a

client whose T4 is 13.5 mcg/dL

A nurse is assessing a client whose total thyroid T4 is 13.5 mcg/dL.

Which of the following manifestations should the nurse expect?

56

RATIONALES – SPECIFIC

Options Rationales

Bradycardia A total thyroid level of T4 is 13.5 mcg/dL is above the expected reference

range and can indicate hyperthyroidism. A client who has

hyperthyroidism has an elevated basal metabolic rate. Therefore, the

nurse should expect to find tachycardia.

Constipation A total thyroid level of T4 is 13.5 mcg/dL is above the expected

reference range and can indicate hyperthyroidism. A client who has

hyperthyroidism has an elevated basal metabolic rate with increased GI

activity. Therefore, the nurse should expect the client to report diarrhea.

Periorbital

edema

A total thyroid level of T4 is 13.5 mcg/dL is above the expected

reference range and can indicate hyperthyroidism. The nurse should

expect to find periorbital edema for a client who has hypothyroidism.

Exophthalmos is an expected finding for a client who has

hypothyroidism.

Hypertension A total thyroid level of T4 is 13.5 mcg/dL is above the expected reference

range and can indicate hyperthyroidism. A client who has

hyperthyroidism has an elevated basal metabolic rate. Therefore, the

nurse should expect to find hypertension.

A nurse is assessing a client whose total thyroid T4 is 13.5 mcg/dL. Which of

the following manifestations should the nurse expect?

RATIONALES - EXAMPLE

A nurse is caring for a client who has acute kidney failure. Which

of the following findings should the nurse expect?

Options Rationales

BUN 29 mg/dL A BUN of 29 mg/dL is above the expected

reference range and is an expected finding for

clients who have acute kidney failure.

Potassium 4.5

mEq/L

A potassium level of 4.5 mEq/L is within the

expected reference range. Hyperkalemia is an

expected finding for clients who have acute

kidney failure.

Bradycardia Tachycardia is an expected finding for clients

who have acute kidney failure.

Restlessness Lethargy is an expected finding for clients who

have acute kidney failure. 57

Key word in question of stem indicates item requires

priority setting

All options are viable actions

One option is the key based on a priority setting

framework

PRIORITY SETTING ITEMS

58

PRIORITY SETTING KEY WORDS

Next

Priority

Imme-diate

First/ Initial

Best

Most Important

59

Which of the following actions should the nurse initiate

first?

Which of the following assessment findings in an older

adult client should the nurse report to the provider

immediately?

Which of the following clients should the nurse assess

first?

Which of the following is the next action the nurse

should take?

PRIORITY SETTING QUESTIONS

60

5/15/2018

11

PRIORITY- SETTING FRAMEWORKS

61

Maslow’s Hierarchy of Needs

Airway - Breathing - Circulation

Safety and Risk Reduction

Nursing Process

Least Restrictive/Least Invasive

Acute vs Chronic/Unstable vs Stable/ Urgent vs Non Urgent

Survival Potential

PRIORITY SETTING FRAMEWORKS Maslow’s Hierarchy of Needs

62

MASLOW’S HIERARCHY ITEM

63

A nurse is planning care for a client who has bipolar

disorder and is experiencing an acute manic episode.

Which of the following is the highest priority intervention

the nurse should include in the plan of care?

A. Give the client with simple directions for completing

ADLs.

B. Offer the client high-calorie fluids frequently.

C. Provide the client with structured solitary activities.

D. Keep the client’s valuables in a locked area.

MASLOW’S HIERARCHY RATIONALES

A. Clients who are having an acute manic episode are likely to have poor

concentration and difficulty completing routine tasks. Providing simple

directions for completing ADLs helps the client focus; however, it’s not the

highest priority.

B. The priority action the nurse should take when using Maslow’s hierarchy of

needs for a client who is experiencing an acute manic episode is to meet the

client’s physiological need for food and water. Therefore, the priority

intervention is to offer the client high-calorie fluids frequently to prevent

calorie deprivation and dehydration .

C. Clients who are having an acute manic episode are likely to have difficulty

focusing on any one activity. Providing the client with structured solitary

activities helps provide focus and feelings of security; however, it’s not the

highest priority.

D. Clients who are having an acute manic episode are likely to give away their

valuables. Keeping the client’s valuables in a locked area prevents the client

from doing so; however, it’s not the highest priority.

64

PRIORITY SETTING FRAMEWORKS Airway-Breathing-Circulation

65

AIRWAY, BREATHING, CIRCULATION

66

A nurse is caring for a client who is wheezing and

gasping for breath just after receiving a dose of

amoxicillin. Which of the following actions is the

nurse’s priority?

A. Administer epinephrine parenterally.

B. Provide reassurance to the client.

C. Initiate an IV infusion of 0.9% sodium chloride.

D. Place client on a cardiac monitor.

5/15/2018

12

67

AIRWAY, BREATHING, CIRCULATION

A. Using the airway, breathing, circulation approach to client care,

the nurse’s priority is to give the client an injection of epinephrine

which will counteract the bronchoconstriction.

B. The nurse should reduce the client’s anxiety by providing

reassurance; however, it’s not the nurse’s highest priority.

C. Starting an IV infusion of 0.9% sodium chloride is important to

maintain fluid balance and provide venous access; however, it’s the

nurse’s highest priority.

D. Attaching the client to a cardiac monitor is important because

medications used to treat anaphylaxis can cause tachycardia and

dysrhythmias; however, it’s not nurse’s highest priority.

PRIORITY SETTING FRAMEWORKS Safety and Risk Reduction

68

SAFETY AND RISK REDUCTION

69

A nurse is planning care for a client who is in

acute alcohol withdrawal. Which of the following

medications should the nurse plan to administer

first?

A. Disulfuram

B. Lorazepam

C. Clonidine

D. Atenolol

70

SAFETY AND RISK REDUCTION

A. Disulfuram is given to support abstinence from alcohol and

prevent relapse; however, this is not the greatest risk to the client

at this time.

B. The greatest risk to the client during acute alcohol withdrawal

is seizures. Therefore, when using the safety and risk reduction

approach to care, the nurse should first administer lorazepam to

control or minimize seizures.

C. Clonidine can help minimize the autonomic symptoms that

occur with acute alcohol withdrawal; however, these are not the

greatest risks to the client at this time.

D. Atenolol can help minimize the autonomic symptoms that

occur with acute alcohol withdrawal; however, these are not the

greatest risks to the client at this time.

PRIORITY SETTING FRAMEWORK Nursing Process

71

NURSING PROCESS

72

A nurse is caring for an adolescent who is to undergo an

open reduction and internal fixation of the ankle following a

sports injury. The client is extremely anxious and having

difficulty sleeping. Which of the following is the priority

intervention?

A. Provide dim lighting in the client’s room.

B. Allow the client’s family to spend the night with him.

C. Offer music as a distraction.

D. Ask the client to tell you what he knows about the

procedure.

5/15/2018

13

73

NURSING PROCESS

A. Providing dim lighting in the client’s room can promote sleep

for some clients; however, this is not the first action the nurse

should take.

B. Allowing the client’s family to stay with him can help reduce his

anxiety; however, this is not the first action the nurse should take.

C. Offering music as a distraction can help reduce his anxiety;

however, this is not the first action the nurse should take.

D. The first action the nurse should take when using the nursing

process is to assess the client. By determining the client’s

understanding of the procedure, the nurse can provide information

needed to help decrease the client’s anxiety.

PRIORITY SETTING FRAMEWORK Least Restrictive/Least Invasive

74

LEAST RESTRICTIVE

75

A nurse is caring for a client who is confused and agitated

and has tried to get out of bed without assistance several

times. Which of the following actions should the nurse

take first?

A. Administer haloperidol intramuscular.

B. Apply chest restraint.

C. Place client in a chair by the nurses’ station.

D. Administer alprazolam orally.

76

LEAST RESTRICTIVE

A. Haloperidol is used to treat confusion and agitation; however,

the nurse should use a less restrictive intervention first.

B. Restraints are used to prevent injury to the client; however, the

nurse should use a less restrictive intervention first.

C. When providing client care, the nurse should first use the Least

Restrictive intervention; therefore, the nurse should place client in

a chair by the nurses’ station where members of the healthcare

team can provide close supervision.

D. Alprazolam is used to treat agitation; however, the nurse should

use a less restrictive intervention first.

LEAST INVASIVE

77

A nurse is caring for a client who gave birth vaginally 8 hr

ago. The client reports feeling weak and dizzy. The nurse

notes that the client’s perineal pad is soaked with blood.

Which of the following actions should the nurse take

next?

A. Administer oxygen at 10L/minute via facemask.

B. Insert an indwelling urinary catheter.

C. Massage the fundus of the uterus.

D. Administer oxytocin 20 units in 1000 mL of lactated

Ringers.

78

LEAST INVASIVE

A. Manifestations of postpartum hemorrhage include saturation of the

perineal pad as well as dizziness and weakness. The nurse may need to

administer oxygen; however, the nurse should use a less invasive

intervention first.…

B. Manifestations of postpartum hemorrhage include saturation of the


insert and indwelling urinary catheter; however, the nurse should use a

less invasive intervention first.

C. Manifestations of postpartum hemorrhage include saturation of the

perineal pad as well as dizziness and weakness. When providing client

care, the nurse should first use the least invasive intervention; therefore,

the first action the nurse should take is to massage the client’s fundus.

D. Manifestations of postpartum hemorrhage include saturation of the


administer oxytocin; however, the nurse should use a less invasive

intervention first.

5/15/2018

14

PRIORITY SETTING FRAMEWORK Acute vs Chronic/Unstable vs Stable/ Urgent vs Non Urgent

79

ACUTE VS NONACUTE

80

A nurse is receiving a hand-off report at the beginning of the shift

for four clients. Which of the following clients should the nurse

assess first?

A. A client who has macular degeneration and does not want to

take his medication.

B. A client who is taking insulin and has an HbA1c of 7%.

C. A client who has Graves’ disease and has exophthalmos.

D. A client who is taking digoxin and is experiencing anorexia.

A. Macular degeneration is a chronic condition that responds to

medication; although the nurse should assess the client to

determine why he does not want to take his medication, this is not

the client the nurse should assess first.

B. An HbA1C reflects a clients blood glucose over the past 3

months; therefore, this is not the client the nurse should assess

first.

C. Exophthalmos is an expected finding for a client who has

Graves’ disease; therefore, this is not the client the nurse should

assess first.

D. Using the Acute vs Chronic approach to client care this is the

first client the nurse should assess first because anorexia is a

possible indication of digoxin toxicity.

81

ACUTE VS NONACUTE STABLE VS UNSTABLE

82

A nurse is reviewing laboratory data for four clients.

Which of the following clients should the nurse assess

first?

A. A client who has atherosclerosis with a total

cholesterol level of 250 mg/dL

B. A client who has chronic kidney disease with a BUN of

80 mg/dL

C. A client who is receiving warfarin with an INR of 4.0

D. A client who is receiving furosemide and has a serum

potassium of 3.8 mEq/L

STABLE VS UNSTABLE

83

A. The nurse should continue to monitor the client who has

atherosclerosis and an elevated total cholesterol level; however

this client is stable and does not need to be assessed first.

B. The nurse should continue to monitor the client who has

chronic kidney disease and an elevated BUN; however this client

is stable and does not need to be assessed first.

C. A client who is receiving warfarin and has an INR of 4.0 is at

risk for hemorrhage. Using the Stable vs Unstable approach to

client care, the nurse should assess this client first.

D. The nurse should continue to monitor the client who receiving

furosemide and has a potassium level within the expected

reference range; however this client is stable and does not need

to be assessed first.

URGENT VS NONURGENT

84

A nurse is caring for a client who has peripheral

arterial disease. Which of the following findings

should the nurse report to the provider

immediately?

A. Report of intermittent claudication

B. Shiny, hairless lower extremities

C. Absent dorsalis pedis pulse

D. Dependent rubor

5/15/2018

15

URGENT VS NONURGENT

85

A. Report of intermittent claudication is an important finding;

however, it is common for clients with peripheral arterial disease to

have this type of pain.

B. Shiny, hairless lower extremities is important finding; however,

clients with peripheral arterial disease usually develop this from

long-term impaired circulation.

C. Using the Urgent vs. Nonurgent approach to client care, the

priority finding is an absent dorsalis pedis pulse. This can indicate

acute arterial occlusion, which requires immediate intervention.

D. Dependent rubor is an important finding; however, clients with

peripheral arterial vascular disease usually develop this from long-

term impaired circulation.

PRIORITY SETTING FRAMEWORK Survival Potential

86

SURVIVAL POTENTIAL

87

A nurse is assessing clients at a mass casualty event

and placing the appropriate triage color tag on each

client. Which of the following tags should the nurse

assign to a client with an abdominal wound that has

eviscerated?

A. Black, “expectant” tag

B. Red, “emergent” tag

C. Yellow, “urgent” tag

D. Green, “nonurgent” tag

SURVIVAL POTENTIAL

88

A. A black expectant tag indicates the client has injuries that are not

consistent with life; therefore, the nurse should not issue a black

expectant tag to a client who has an abdominal wound that has

eviscerated.

B. A red emergent tag indicates the client has injuries that are life-

threatening and need immediate attention; therefore, when using the

survival potential approach to client care, the nurse should issue a red

emergent tag to this client.

C. A yellow urgent tag indicates the client has injuries that need

attention but are not life-threatening; therefore, the nurse should not

issue a yellow urgent tag to a client who has an abdominal wound that

has eviscerated.

D. A green nonurgent tag indicates the client has minor injuries that do

not need immediate treatment; therefore, the nurse should not issue a

green nonurgent tag to a client who has an abdominal wound that has

eviscerated.

89

• Remember

• Understand Foundational

Thinking

• Apply

• Analyze

• Evaluate

• Create

Critical Thinking / Clinical

Judgment

LEVELS OF THINKING FOUNDATIONAL THINKING

Causes/risk factors

Signs and symptoms

Steps of a procedure

Medication purpose/mechanism of action

Laboratory values (expected reference range)

90

5/15/2018

16

FOUNDATIONAL THINKING ITEM STEMS

Stems –

― A client is prescribed furosemide. The nurse should recognize

that which of the following laboratory values is outside the

expected reference range?

― A client admitted to the medical unit is diagnosed with

hyperthyroidism. Which of the following would be an expected

assessment finding?

― A client has been recently diagnosed with cancer of the larynx.

Upon review of the systems the nurse recognizes which of the

following findings as a risk factor for this type of cancer?

91

Calculate drug dosages.

Choose appropriate nursing interventions.

Choose the highest priority finding/nursing action, etc.

Evaluate the effectiveness of teaching.

Examine/select from alternative solutions.

Identify desired outcome, potential risk or complication.

Draw conclusion/make inferences from two or more

pieces of data

Use therapeutic communication.

92

CRITICAL THINKING / CLINICAL JUDGMENT

CRITICAL THINKING / CLINICAL JUDGMENT

ITEM STEMS

Stems –

― A nurse is caring for a client who is 6 hr postoperative from a

vaginal hysterectomy. Which of the following findings requires

follow-up by the nurse?

― An assistive personnel reports a blood glucose level of 458

mg/dL for a client who has type II diabetes mellitus. Which of

the following actions should the nurse take?

― A nurse is caring for a client who has a serum calcium of 8.1

mg/dL. The nurse should monitor the client for which of the

following?

93

PEER/GROUP ACTIVITY

In your peer dyads, rewrite each stem making it a Critical Thinking / Clinical Judgment level item stem

― A client is prescribed furosemide. The nurse should recognize that which of the following laboratory values is outside the expected reference range?

― A client admitted to the medical unit is diagnosed with hyperthyroidism. Which of the following would be an expected assessment finding?

― A client has been recently diagnosed with cancer of the larynx. Upon review of the systems the nurse recognizes which of the following findings as a risk factor for this type of cancer?

94

QUESTIONS?

95

REFERENCES Anderson, L.W., Kraftwohl, D.R., Airasian, P. W., Cruikshank, K.A., Mayer, R.E., Pintrich, P.R., Raths, & Wittrock, M.C. (2001) A taxonomy for learning, teaching, and assessing: A revision of Bloom’s Taxonomy of educational objectives. Boston: MS, Allyn & Bacon.

Billings, D.M. & Halstead, J.A. (2016) Teaching in Nursing: A Guide for Faculty. St.

Louis, MO: Elsevier

Collins, J. (2006) Writing multiple-choice questions for continuing medical education activities and self-assessment modules. RadioGraphics, 26 (2).

Downing, S.M. (2005) The effects of violating standard item writing principles on tests and students: The consequences of using flawed test items on achievement examinations in medical education. Advances in Health Sciences Education, 10(2).

National Council of State Boards of Nursing. (2016). NCLEX-RN® Examination: Test plan for the National Council licensure examination for registered nurses. Retrieved from https://www.ncsbn.org/RN_Test_Plan_2016_Final.pdf

96

5/15/2018

17

REFERENCES

National Council of State Boards of Nursing. (2017). NCLEX-PN® Examination: Test

plan for the National Council licensure examination for nurses. Retrieved from

https://www.ncsbn.org/PN_Test_Plan_2017_Educator_v2.pdf

Nedeau-Cayo, R., Laughlin, D., Rus, L., & Hall, J. (2013). Assessment of item-writing

flaws in multiple-choice questions. Journal for Nurses in Professional Development. 29(2).

Oermann, M.H. (2015) Teaching in Nursing and Role of the Educator. New York, NY:

Springer.

Tarrant, M., Knierim, A., Hayes, S.K., & Ware, J. (2006). The frequency of item writing flaws

in multiple-choice questions used in high stakes nursing assessment. Nursing Education

in Practice, 6(6).

Wyas, R., & Supe, A. (2008) Multiple choice questions: A literature review on the optimal

number of options. The National Medical Journal of India, 21(3).

97

item writing objectives begin with the end in mind: the ... · 5/15/2018 1 begin with the end in...

Documents