BONUS CONTENT FROM LPN2009

Arm yourself with these test-taking strategies
By Barbara B. Pope, RN, CCNS, CCRN, PCCN, MSN

Many nurses confess they have difficulty taking tests, particularly certification exams. Certification exams are purposely challenging; certification would be meaningless if they weren't. Certainly, candidates must be knowledgeable, and success requires preparation. Even after intense studying, however, many competent, skilled nurses perform poorly. Fortunately, a little preparation (and a lot of studying) will go a long way toward helping you attain your certification.

What's your learning style?
Recognizing your own learning style can improve your preparation and better your chances of success. If you prefer a classroom setting, find a course being offered in your area. Check with your professional organization's Web site, such as http://www.aacn.org, the Web site of the American Association of Critical-Care Nurses (AACN), or http://www.sccm.org, the Society of Critical Care Medicine's (SCCM) Web site. You'll find listings for courses available throughout the country. Also, call your organization's local chapter. They may be offering a course, or be aware of courses in your area.

If you prefer to study online, self-assessment exams (SAEs) are available for both the CCRN and PCCN exams. You have 90 days to take the exam from the time you receive your validation number, and you'll have access to the SAEs during that time. The SAEs use sample questions for practice, along with rationales for the correct answer.

Several certification exam preparation books include CD-ROMs, which feature practice questions similar to the certification exam. These are available at the publisher's Web site and online or at local bookstores. Be sure to check the publication date if you prefer to study from books. The exams are updated approximately every 3 years; books published earlier may contain out-of-date information.

Finally, study groups can be helpful to your preparation as well. Find out if there are other nurses in your hospital interested in taking the exam. Then, talk with your educator, clinical nurse specialist, or manager and ask if she would be willing to guide the study sessions or share any experiences that may assist you.

Preparing for the exam
Plan to study a little bit each day and start early, giving yourself plenty of time to absorb the information without becoming overwhelmed. Also, take a trip to the testing site in advance so you know exactly where it is and how long it takes to get there. Most testing regulations won't permit you to take the exam if you're more than 15 minutes late. Plan to arrive at the testing site 30 to 45 minutes before schedule in case of traffic or if you get lost.

The night before the exam, don't stay up late studying or try to cram. You'll be more successful if you're well-rested. Instead, briefly review your weakest areas. Alcohol or caffeine can interfere with your sleep, so stay away from them after dinner.

Also, lay out the clothes you plan to wear; you'll avoid last-minute panic if you know exactly where your lucky jeans are! Plan to wear comfortable, layered clothing. The exam can take up to 3 hours, and tight clothes could be distracting. Layered clothing will keep you comfortable regardless of room temperature because you can take off layers if it's warm.

On the morning of the exam, be sure to eat breakfast, and take this time to briefly review your weak areas again. Once again, try to avoid too much caffeine. Its diuretic properties could have you out of your seat during the exam, and these bathroom breaks are taken out of your testing time.

During the exam
Usually, you're allowed to wear a watch and bring a calculator. Everything else you bring will be placed in safekeeping until after the exam. Be sure to wear a watch so you can keep track of time as you complete the exam. After an hour, check to see if you have answered at least 50 questions. Most likely, you'll have answered more than 50, but if you haven't, you'll know that you need to pick up the pace to complete the exam on time.

When taking the exam, read the questions carefully. Missing a key word can change your understanding of the question, leading to an incorrect answer. At the same time, try not to spend more than 2 minutes on each question. There's no penalty for guessing, so if you don't know an answer, take a guess. Once you answer, don't change it unless you realize you misread the question. One of the major reasons why test-takers fail is changing a right answer to a wrong answer. You might not consciously remember the answer, but your subconscious might. By changing your answer, you're overriding your subconscious.

You may also be able to improve your chances of getting the question right by eliminating two of the distractors (wrong answers). Be careful not to “read into” a question or think of unusual patients you've had in the past. The exam will test you on typical patient presentations.

“Reading into” a question means you're making assumptions that aren't stated in the scenario. For example, a question describing a postoperative patient who suddenly becomes dyspneic and tachypneic, with generalized chest discomfort wants you to diagnose the situation. Although one of the choices is pneumothorax, which may also include these signs and symptoms, there's nothing in the scenario to suggest that the patient was at risk for this situation, and no mention of unilateral decreased or absent breath sounds. Instead, this patient is probably experiencing a pulmonary embolism.

Question structure
Often, there are clues in the structure of the questions that can help you find the correct answer. Occasionally, there will be two answers that are correct and you'll need to know how to select the best one. Look at the example below:
A left-sided tension pneumothorax is best described as an accumulation of air in the:
A. left pleural space, resulting in collapse of the left lung.
B. right pleural space, resulting in collapse of the left lung.
C. left pleural space, resulting in collapse of the left lung and compression of the right thoracic structures.
D. left pleural space, resulting in collapse of the right lung and compression of the right thoracic structures.

Both A and C are correct. Since C contains the additional information of “compression of the right thoracic structures,” this is the correct answer. This shows the depth of your knowledge about the situation.

Another common format tests your ability to prioritize. Although in practice, you would have assistance from others if your patient's clinical status deteriorated, these questions are designed to evaluate your ability to recognize the most important intervention to perform first. Questions like this often use words such as first, best, most, initial, better, or highest priority. All of your choices might be correct, but one has the highest priority, or one or two might actually be incorrect. Look for interventions that address airway, breathing, and circulation, which always have the highest priority.

It's also important to understand the various disease pathologies. Here's a sample question on diabetic ketoacidosis (DKA):
A patient is admitted with a diagnosis of DKA. Her serum glucose level is 752 mg/dL. Additional testing shows an elevated serum ketone level and ketonurea. Arterial blood gases reveal a metabolic acidosis with a pH of 7.24. Your initial intervention would be to:
A. begin a continuous I.V. infusion of regular insulin.
B. monitor serum potassium levels.
C. administer a liter of I.V. normal saline solution (NSS).
D. administer sodium bicarbonate.

The first three choices are all appropriate for this patient. The most important one, however, is to address the serious dehydration that often develops in DKA patients. Therefore, C is the correct answer. Hanging the insulin infusion (A) is the next most important intervention, followed by monitoring the serum potassium (B). You wouldn't administer sodium bicarbonate (D) unless the pH dipped below 7.2.

Negative words, such as not, least, except, inconsistent, all but, atypical, incorrect, false, unlikely, inappropriate, unrealistic, and contraindicated are usually not used in the exam. Questions using negative words reverse your answers. Instead of looking for the one action you would do, you're looking for the one you wouldn't do. This type of question leads to incorrect answers so often it makes them invalid. However, negative questions can appear more subtly. Often, they’re in the form of a prescriber's order that you would question. Here's an example:
A patient is admitted with a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following orders would the nurse question?
A. Neurological assessment every 4 hours
B. Serum sodium level every 4 hours
C. Infusion of 1 liter NSS I.V. at 100 mL/hour
D. Strict intake and output

Be sure to read the question carefully and recognize what's being asked. All of the above orders are appropriate for this patient except C. The patient is already volume overloaded; additional fluid administration isn't warranted. A hypertonic solution of 3% sodium chloride solution may be ordered in severe SIADH, but this wasn't indicated in the scenario.

Very few situations are absolute. Selections that use absolute words, such as always, every, only, all, never, or none are most likely incorrect and should be avoided. For example:
Which of the following statements regarding pulmonary embolism (PE) is true?
A. Treatment for PE always includes mechanical ventilation.
B. PE only occurs in patients with deep vein thrombosis.
C. Patients with PE never have pleuritic pain.
D. Patients with PE usually present with sudden dyspnea.

The first three answers all contain absolute wording. Answer D is correct.

Sometimes you simply won't know an answer. Look for clues that might indicate the answer. For example:
For several years, Karen Cooper has been treated for severe chronic emphysema with bronchodilating agents and relatively high doses of prednisone (Deltasone). Which activity poses the least risk for triggering an adverse effect of prednisone therapy in this patient?
A. Shopping at the mall on a Saturday afternoon
B. Cleaning her two-story house
C. Attending Sunday morning church services
D. Serving refreshments at her 6-year-old son's school play

To answer this question, you only need to know that immunosuppression is an adverse reaction of long-term steroid use. Since answers A, C, and D all involve contact with people, who may have a cold or other infection, the safest activity is B, cleaning her house.

Some questions are very lengthy, and give a lot of information. You'll need to wade through them to pick out significant clues. For example:
A patient was admitted to the ICU following abdominal surgery for a stab wound 3 days ago. His current vital signs have deteriorated in the last few hours. They now are: BP 87/52; heart rate 130, respiratory rate 32, temperature 102.1° F. He receives 2 L of I.V. NSS over 60 minutes but remains hypotensive. His urine output for the past 2 hours is 25 ml/hour. His blood urea nitrogen is 50 mg/dL and his creatinine is 5.1 mg/dL. His mentation has progressively worsened and he is now responsive only to painful stimuli. His chest X-ray shows bilateral infiltrations. His point-of-care blood glucose is 225 mg/dL. A diagnosis is made of sepsis with multiple organ dysfunction syndrome. What is the nurse's priority goal for this patient?
A. Ensuring nutritional needs are met
B. Maintaining adequate tissue oxygenation
C. Changing the patient's pain medication from patient-controlled analgesia to continuous infusion
D. Obtaining blood, sputum, urine and wound cultures

Although all of these are appropriate goals for this patient, adequate oxygenation, B, is the priority goal. Airway, breathing, and circulation goals should always be considered if they’re one of the choices.

Stay positive
Above all, remember to keep a positive attitude and try to stay relaxed. You've worked hard at your preparation and earning your nursing degree. By incorporating these strategies, you'll increase your chances of success at achieving your certification as well.

Selected references
Alspach JG, ed. American Association of Critical-Care Nurses Core Curriculum for Critical Care Nursing. 6th ed. Philadelphia, PA: W.B. Saunders Company; 2006.
Sole ML, Klein DG, Moseley MJ. Introduction to Critical Care Nursing. 4th ed. St. Louis, MO: Elsevier Saunders; 2005.
Springhouse Review for Critical Care Nursing Certification. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.
Urden LD, Stacy K M, Lough ME. Thelan's Critical Care Nursing: Diagnosis and Management. 5th ed. St. Louis, MO: Mosby, Inc; 2005.

Resources
PCCN SAE information: http://www.aacn.org/WD/Certifications/Content/saeexampccn.pcms?menu=Certification
CCRN SAE information: http://www.aacn.org/WD/Certifications/Content/saeexam.pcms?menu=Certification
Locating a testing center: http://www.goamp.com/displayTCList.aspx?pExamID=20347

Source: Nursing2009 Critical Care. March 2009.