Special Features of the Book

Pyramid Terms

Pyramid Terms are important to the discussion of the content in the chapters in each

unit. Therefore, they are in bold green type throughout the content section of each

chapter. Definitions can be reviewed in the Audio Glossary on the Evolve site.

Pyramid to Success

The Pyramid to Success, a featured part of each unit introduction, provides you with

an overview, guidance, and direction regarding the focus of review in the particular

content area, as well as the content area’s relative importance to the 2019 test plan for

the NCLEX-RN examination. The Pyramid to Success reviews the Client Needs and

provides learning objectives as they pertain to the content in that unit. These

learning objectives identify the specific components to keep in mind as you review

each chapter.

Priority Concepts

Each chapter identifies two Priority Concepts reflective of its content. These Priority

Concepts will assist you to focus on the important aspects of the content and

associated nursing interventions.

Pyramid Points

Pyramid Points ( ) are placed next to specific content throughout the chapters.

The Pyramid Points highlight content that is important for preparing for the NCLEXRN examination and identify content that is likely to appear on the NCLEX-RN

examination.

Pyramid Alerts

Pyramid Alerts are the red text found throughout the chapters that alert you to

important information about nursing concepts. These alerts identify content that

typically appears on the NCLEX-RN examination.

Special Features Found on Evolve

Pretest and Study Calendar

The accompanying Evolve site contains a 75-question pretest that provides you with

feedback on your strengths and weaknesses. The results of your pretest will generate

an individualized study calendar to guide you in your preparation for the NCLEXRN examination.

Heart, Lung, and Bowel Sound Questions

35

The accompanying Evolve site contains Audio Questions representative of content

addressed in the 2019 test plan for the NCLEX-RN examination. Each question

presents an audio clip as a component of the question.

Video Questions

The accompanying Evolve site contains Video Questions representative of content

addressed in the 2019 test plan for the NCLEX-RN examination. Each question

presents a video clip as a component of the question.

Case Study (Testlet) Questions

The accompanying Evolve site contains case study questions. These question types

include a client scenario and several accompanying practice questions that relate to

the content of the scenario.

Audio Review Summaries

The companion Evolve site includes three Audio Review Summaries that cover

challenging subject areas addressed in the 2019 test plan for the NCLEX-RN

examination, including Pharmacology, Acid-Base Balance, and Fluids and Electrolytes.

Practice Questions

While preparing for the NCLEX-RN examination, it is crucial for students to practice

taking test questions. This book contains 945 NCLEX-style multiple-choice and

alternate item format questions. The accompanying software includes all questions

from the book plus additional Evolve questions for a total of more than 5200

questions.

Multiple-Choice and Alternate Item Format Questions

Starting with Unit II, each chapter is followed by a practice test. Each practice test

contains several questions reflective of the content in the chapter and those

presented on the NCLEX-RN examination. These questions provide you with

practice in prioritizing, decision-making, critical thinking, and clinical judgment

skills. Chapter 1 of this book provides a description of each question type. Sample

questions of the Next Generation NCLEX (NGN) are also provided in this chapter.

The answer section for each practice question throughout the chapters and on the

Evolve site provides the correct answer, the rationale for the correct and incorrect

options, and a specific test-taking strategy that will assist you in answering the

question correctly. The specific test-taking strategy is highlighted in bold blue type.

This highlighting will provide you with guidance and direction for further

remediation in the Saunders Strategies for Test Success: Passing Nursing School and the

NCLEX® Exam.

The categories identified in each practice question include Level of Cognitive

Ability, Client Needs, Integrated Process, the specific nursing Content Area, the

Health Problem, and Priority Concepts. Every question on the accompanying Evolve

36

site is organized by these question codes, so you can customize your study session to

be as specific or as generic as you need. Additionally, a link to view normal

laboratory reference intervals are provided with each practice question.

Pharmacology and Medication Calculations

Review

Students consistently state that pharmacology is an area with which they need

assistance. The 2019 NCLEX-RN test plan continues to incorporate pharmacology in

the examination, but only the generic drug names will be included. Therefore,

pharmacology chapters have been included for your review and practice. This book

includes 13 pharmacology chapters, a medication and intravenous prescriptions

calculation chapter, and a pediatric medication administration and calculation

chapter. Each of these chapters is followed by a practice test that uses the same

question format described earlier. This book contains numerous pharmacology

questions. Additionally, more than 950 pharmacology questions can be found on the

accompanying Evolve site.

Next Generation NCLEX (NGN) Questions

The NCSBN is currently piloting research questions for a project known as the “Next

Generation NCLEX.” An NCLEX candidate may encounter these questions once

they complete their examination, and they will have the option to answer these

questions as part of NCSBN’s research on these new item types. The NCSBN is

aiming to launch the NGN questions on the examination sometime during the years

2022-2023, and these item types are designed to test the candidate’s ability to make

safe and competent clinical judgments. This resource incudes 25 NGN item types,

and although it is not live on the NCLEX now, practicing these items will assist the

current candidate in preparing for the NCLEX examination. The NGN questions are

located on the Evolve site.

How to Use This Book

Saunders Comprehensive Review for the NCLEX-RN® Examination is especially

designed to help you with your successful journey to the peak of the Saunders

Pyramid to Success: becoming a registered nurse! As you begin your journey through

this book, you will be introduced to all of the important points regarding the 2019

NCLEX-RN examination, the process of testing, and unique and special tips

regarding how to prepare yourself for this very important examination.

You should begin your process through the Saunders Pyramid to Success by

reading all of Unit I in this book and becoming familiar with the central points

regarding the NCLEX-RN examination. Be sure to read Chapter 3, written by a

nursing graduate who recently passed the examination, and note what she has to say

about the testing experience. Chapter 4 will provide you with the critical testing

strategies that will guide you in selecting the correct option or assist you in selecting

an answer to a question if you must guess. Keep these strategies in mind as you

37

proceed through this book. Continue by studying the specific content areas

addressed in Units II through XIX. Review the definitions of the Pyramid Terms

located in each chapter, and the Pyramid to Success notes, and the Client Needs and

Learning Objectives located in each unit introduction. Read through the chapters

and focus on the Pyramid Points and Pyramid Alerts that identify the areas most likely

to be tested on the NCLEX-RN examination. Pay particular attention to the Priority

Nursing Actions boxes because they provide information about the steps you will

take in clinical situations requiring clinical judgment and prioritization.

As you read each chapter, identify your areas of strength and those in need of

further review. Highlight these areas and test your abilities by taking all practice

tests provided at the end of the chapters. Be sure to review all rationales and testtaking strategies.

After reviewing all chapters in the book, turn to Unit XX, Chapter 70, the

Comprehensive Test. Take this examination and then review each question, answer,

and rationale. Identify any areas requiring further review; then take the time to

review those areas in both the book and the companion Evolve site. In preparation

for the NCLEX-RN examination, be sure to take the pretest and generate your study

calendar. Follow the calendar for your review because the calendar represents your

pretest results and the best study path to follow based on your strong and weak

content areas. Also, be sure to access the Case Studies and the Audio Review Summaries

as part of your preparation for the NCLEX-RN examination.

Climbing the Pyramid to Success

The purpose of this book is to provide a comprehensive review of the nursing

content you will be tested on during the NCLEX-RN examination. However,

Saunders Comprehensive Review for the NCLEX-RN® Examination is intended to do

more than simply prepare you for the rigors of the NCLEX-RN examination; this

book is also meant to serve as a valuable study tool that you can refer to throughout

your nursing program, with specific customizable Evolve site selections to help

identify and reinforce key content areas and prepare you for your nursing exams.

After using this book for comprehensive content review, your next step in the

Pyramid to Success is to get additional practice with the Q&A review product.

Saunders Q&A Review for the NCLEX-RN® Examination offers more than 6000 unique

practice questions in the book and on the companion Evolve site. The questions are

focused on the Client Needs and Integrated Processes of the NCLEX-RN test plan,

making it easy to access your study area of choice. For on-the-go Q&A review, you

can pick up Saunders Q&A Review Cards for the NCLEX-RN® Examination.

Your final step on the Pyramid to Success is to master the online review. Saunders

Online Review for the NCLEX-RN® Examination provides an interactive and

individualized platform to get you ready for your NCLEX exam. This online course

provides 10 high-level content modules, supplemented with instructional videos,

animations, audio, illustrations, case studies, and several subject matter exams. Endof-module practice tests are provided along with several Crossing the Finish Line

practice tests. In addition, you can assess your progress with a Pretest, Test Yourself

quizzes, and a Comprehensive Exam in a computerized environment that prepares you

for the actual NCLEX-RN examination.

At the base of the Pyramid to Success are our test-taking strategies, which provide

38

a foundation for understanding and unpacking the complexities of NCLEX-RN

examination questions, including alternate item formats. Saunders Strategies for Test

Success: Passing Nursing School and the NCLEX® Exam takes a detailed look at all of

the test-taking strategies you will need to know in order to pass any nursing

examination, including the NCLEX-RN. Special tips are integrated for nursing

students, and there are more than 1200 practice questions included so you can apply

the testing strategies. NGN questions are included on the Evolve site.

Good luck with your journey through the Saunders Pyramid to Success. We wish

you continued success throughout your new career as a registered nurse!

39

Acknowledgments

A Few Words From Linda

There are many individuals who in their own ways have contributed to my success

in making my professional dreams become a reality. My sincere appreciation and

warmest thanks are extended to all of them.

First, I want to acknowledge my parents, who opened my door of opportunity in

education. I thank my mother, Frances Mary, for all of her love, support, and

assistance as I continuously worked to achieve my professional goals. I thank my

father, Arnold Lawrence, who always provided insightful words of encouragement.

My memories of their love and support will always remain in my heart. I am certain

that they are very proud of my professional accomplishments.

I also thank my best friend and love of my life, my husband, Larry; my sister,

Dianne Elodia, and her husband, Lawrence; my brother, Lawrence Peter, and my

sister-in-law, Mary Elizabeth; my cousin Paula; and my nieces and nephews, Angela,

Gina, Karen, Katie, Brianna, and Nicholas, who were continuously supportive,

giving, and helpful during my research and preparation of this publication. They

were always there and by my side whenever I needed them.

I want to thank my nursing students at the Community College of Rhode Island

who approached me in 1991 and persuaded me to assist them in preparing to take

the NCLEX-RN examination. Their enthusiasm and inspiration led to the

commencement of my professional endeavors in conducting review courses for the

NCLEX-RN examination for nursing students. I also thank the numerous nursing

students who have attended my review courses for their willingness to share their

needs and ideas. Their input has certainly added a special uniqueness to this

publication.

I also wish to acknowledge all of the nursing faculty who taught in my review

courses for the NCLEX-RN examination. Their commitment, dedication, and

expertise have certainly assisted nursing students in achieving success with the

NCLEX-RN examination. I also want to extend a very special thank you to my niece,

Angela, for joining me in preparing and authoring these NCLEX resources. Angela is

wonderful to work with. Her tremendous theoretical and clinical knowledge and

expertise and her consistent ideas and input certainly added to the excellent quality

of this product. She is very dedicated to promoting and ensuring student success.

Thank you, Angela!

A special thank you goes to Loren Wilson, former Senior Vice President, for her

years of expert guidance and continuous support for all of the products in the

Pyramid to Success.

I would also like to acknowledge Patricia Mieg, former educational sales

representative, who encouraged me to submit my ideas and initial work for the first

edition of this book to the W.B. Saunders Company.

40

I also need to thank Salve Regina University for the opportunity to educate

nursing students in the baccalaureate nursing program and for its support during

my research and writing of this publication. I would like to especially acknowledge

my colleague Dr. Eileen Gray for all of her encouragement and support and

dedication to my professional endeavors.

I wish to acknowledge the Community College of Rhode Island, which provided

me with the opportunity to educate nursing students in the Associate Degree of

Nursing Program. A special thank you goes to Patricia Miller, MSN, RN, and

Michelina McClellan, MS, RN, from Baystate Medical Center, School of Nursing, in

Springfield, Massachusetts, who were my first mentors in nursing education.

And finally, a very sincere and special acknowledgment to my husband, Laurent

(Larry) W. Valliere, for his contribution to this publication, for teaching in my review

courses for the NCLEX-RN examination, and for his commitment and dedication in

assisting my nursing students to prepare for the examination from a nonacademic

point of view. I thank him for all of his continuous support; he was so loyal and

loving to me each and every moment as I worked to achieve my professional goals.

Larry, you are my “rock of support!” Thank you so much!

A Few Words From Angela

There are many people who contributed to my success in my work on this product. I

am very grateful for their continued support in all of my endeavors.

First and foremost, I would like to thank my husband, Brent, for his light-hearted

and positive attitude. He always knows how to make me laugh, especially when I’m

stressed. All of this would not be possible without him!

I would also like to thank my parents, Mary and Larry, for their continued support

throughout the years. Their words of encouragement and wisdom have been

tremendously important to my success. I also don’t know what I would do without

their support in caring for my kids!

I would like to thank my sister Katie, who is a wonderful nurse. Her ambitions as

a nursing student were so inspiring and reminded me about why I’m so passionate

about being an educator. Thank you to my brother, Nick, who always is positive and

encouraging about my work. His wit and sarcasm are always a great way to lift your

mood at the end of the day. I would also like to thank my friends Jessica, Alena, and

Lisa for their continued support, encouragement, and camaraderie throughout my

professional endeavors.

Finally, I want to extend a special thank you to Linda for her collaboration,

guidance, and expertise. Without her, I would not be where I am today. Thank you,

Linda!

A Few Words From Both Linda and Angela

First and foremost, we want to thank our associate editor, Katie Silvestri, for all of

her dedicated and hard work in editing and preparing manuscript for this edition.

Her expertise and close attention to details have certainly added to the quality of this

resource. In addition, we sincerely thank Katie for writing a chapter for this book

about her experiences with preparing for and taking the NCLEX-RN examination.

41

Katie, thank you so much!

We also want to acknowledge and thank Laurent W. Valliere for writing a chapter

addressing those important nonacademic test preparation issues.

A very special thank you and acknowledgment goes to all of the reviewers,

contributors, and item writers who updated and provided many of the practice

questions and all of the previous contributors who provided contributions to this

book.

Additionally, we want to thank Paula Richards for her expertice and input in

creating our new chapter, titled Care of Special Populations. Thank you, Paula!

We wish to offer a very special acknowledgment and thank you to Jane Tyerman

for reviewing many sections of this book, including the Mental Health section, to

ensure that it included Canadian nursing practice and standards. Thank you, Jane!

We would also like to thank other reviewers and contributors who spent so much

of their own time reviewing and/or contributing to the new chapters of the book and

the specialty sections of this book. Their expertise has certainly added to the quality

of this book. Thank you, Jessica Grimm and David Peterson, for your expertise in

reviewing the new Complex Care chapter. Thank you, Lisa Nicholas, for your

expertise in reviewing and updating developmental stages. Thank you, Eileen Gray,

for your updates in Pediatrics; and thank you, Carmen George, for your updates in

Maternity. Finally, thank you, Debra Hagler, for your expertise in updating the

cardiovascular section of this edition. In addition, a special thank you to both,

Veronica Vital and Kimberly Head, for reviewing our new Special Populations

chapter.

We thank Dianne E. Fiorentino for her continuous support and dedication to our

work and in her reference support and other secretarial responsibilities for the eight

editions of this book. We thank Jimmy Guibault for providing medication research

support, and Nick Silvestri for his communication and proofreading skills as he

reviewed the manuscript. And we thank Mary and Larry Silvestri for their assistance

with all of the tasks and projects we needed completed. A special thank you to all of

you!

We thank all of our student and graduate reviewers who read all of the practice

questions in this book and provided input on their quality. And we sincerely extend

a very special thank you to Kristen Hickey, a nursing graduate, who edited and

coded all of our practice questions on the Evolve site.

We sincerely acknowledge and thank some very important and special people

from Elsevier. We thank Jamie Blum, Senior Content Strategist, and Laurie Gower,

Director of Development, for their continuous support, enthusiasm, and expert

professional guidance throughout the preparation of this edition. And a very special

thank you goes to Laura Goodrich, Senior Content Development Specialist, for her

tremendous amount of support and assistance, for prioritizing for us to keep us on

track, for her ideas for the product, and for her professional and expert skills in

organizing and maintaining an enormous amount of manuscript for production. We

could not have completed this project without Laura—thank you, Laura!

We want to acknowledge all of the staff at Elsevier for their tremendous help

throughout the preparation and production of this publication. A special thanks to

all of them. We thank Julie Eddy, Publishing Services Manager and Amy Buxton,

Designer. You have all played such significant roles in finalizing this publication. We

need to especially acknowledge Cindy Thoms, Senior Project Manager, who took

42

over when Laura was on maternity leave. Cindy, you were so supportive and so

awesome to work with. Your attention to the many details to ensure and maintain

the quality of this book was so greatly appreciated. We thank you so much!

Lastly, a very special thank you to all our nursing students: past, present, and

future. All of you light up our life! Your love and dedication to the profession of

nursing and your commitment to provide health care will bring never-ending

rewards!

43

UNIT I

NCLEX-RN® Exam Preparation

44

C H A P T E R 1

The NCLEX-RN® Examination

http://evolve.elsevier.com/Silvestri/comprehensiveRN/

The Pyramid to Success

Saunders Comprehensive Review for the NCLEXRN® Examination

About This Resource and the NCLEX-RN® Examination

Welcome to the Pyramid to Success and Saunders Comprehensive Review for the NCLEXRN® Examination. This resource is specially designed to help you begin your

successful journey to the peak of the pyramid, becoming a registered nurse. As you

begin your journey, you will be introduced to all of the important points regarding

the NCLEX-RN examination and the process of testing, and to unique and special

tips regarding how to prepare yourself for this important examination. You will read

what a nursing graduate who recently passed the NCLEX-RN examination has to

say about the test. Important test-taking strategies are detailed. These details will

guide you in selecting the correct option or assist you in making an educated guess if

you are not entirely sure about the correct answer. Each unit in this book begins with

the Pyramid to Success. The Pyramid to Success addresses specific points related to

the NCLEX-RN examination. Client Needs as identified in the test plan framework

for the examination are listed, as are learning objectives for the unit. Pyramid Terms

are key words that are defined in the glossary at the end of the book and set in color

throughout each chapter to direct your attention to significant points for the

examination.

This resource provides you with nursing content review, including the content

identified in the current NCLEX test plan, and practice questions. Throughout each

chapter, you will find Pyramid Point bullets that identify areas most likely to be

tested on the NCLEX-RN examination. Read each chapter, and identify your

strengths and areas that are in need of further review.

The book contains 945 NCLEX-style questions. The Evolve site accompanying this

book contains all of the questions from the book plus additional Evolve questions for

a total of more than 5200 practice questions. The types of practice questions include

multiple choice; fill-in-the-blank; multiple-response; ordered-response (also known

as drag and drop); questions that contain a figure, chart/exhibit, or graphic option

item; audio or video item formats; and case studies (testlets). In addition, the new

Next Generation NCLEX® (NGN) question types are also provided on the

accompanying Evolve site. Examples of question types can be located throughout

this chapter.

Test your strengths and abilities by taking all practice tests provided in this book

and on the accompanying Evolve site. Be sure to read all rationales and test-taking

45

strategies. The rationale provides you with significant information regarding the

correct and incorrect options. The test-taking strategy provides you with the logical

path to selecting the correct option. reference source and page number are provided

so that you can easily find information you need to review in another Elsevier text.

You may also review in the content review sections of this book. Each question in the

book and on the accompanying Evolve site is coded on the basis of the Level of

Cognitive Ability, the Client Needs category, the Integrated Process, Content Area

being tested, and a Health Problem, if applicable. The Health Problem code allows

you to filter and select questions based on a disease process. For example, if heart

failure is the area of interest, you can select “Adult Health, Cardiovascular, Heart

Failure” on the Evolve site. In addition, two Priority Concepts that relate to the

content of the question are identified. This code is helpful for students specifically

whose curriculum is concept-based. Additionally, information about all of the

special features of this resource and the question types is located in the preface of

this book.

Other Resources in the Saunders Pyramid to Success

There are several other resources in the Saunders Pyramid to Success program.

These include the following: The Saunders Q&A Review for the NCLEX-RN®

Examination, The HESI/Saunders Online Review for the NCLEX-RN® Examination,

Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam,

Saunders Q&A Review Cards for the NCLEX-RN® Exam, and Saunders RNtertainment

for the NCLEX-RN® Exam.

All of these resources in the Saunders Pyramid to Success are described in the

preface of this book and can be obtained online by visiting http://elsevierhealth.com

or by calling 800-545-2522.

Let’s begin our journey through the Pyramid to Success.

Examination Process

An important step in the Pyramid to Success is to become as familiar as possible

with the examination process. Candidates facing the challenge of this examination

can experience significant anxiety. Knowing what the examination is all about and

knowing what you will encounter during the process of testing will assist in

alleviating fear and anxiety. The information contained in this chapter was obtained

from the NCSBN Web site (www.ncsbn.org) and from the NCSBN 2019 test plan for

the NCLEX-RN and includes some procedures related to registering for the exam,

testing procedures, and the answers to the questions most commonly asked by

nursing students and graduates preparing to take the NCLEX. You can obtain

additional information regarding the test and its development by accessing the

NCSBN Web site and clicking on the NCLEX Exam tab or by writing to the National

Council of State Boards of Nursing, 111 East Wacker Drive, Suite 2900, Chicago, IL

60601. You are encouraged to access the NCSBN Web site, because this site provides

you with the most up-to-date and valuable information about the NCLEX and other

resources available to an NCLEX candidate. You are also encouraged to access the

most up-to-date Candidate Bulletin. This document provides you with everything you

need to know about registration procedures and scheduling a test date.

46

Computer Adaptive Testing

The acronym CAT stands for computer adaptive test, which means that the

examination is created as the test-taker answers each question. All the test questions

are categorized on the basis of the test plan structure and the level of difficulty of the

question. As you answer a question, the computer determines your competency

based on the answer you selected. If you selected a correct answer, the computer

scans the question bank and selects a more difficult question. If you selected an

incorrect answer, the computer scans the question bank and selects an easier

question. This process continues until all test plan requirements are met and a

reliable pass-or-fail decision is made.

When taking a CAT, once an answer is recorded, all subsequent questions

administered depend, to an extent, on the answer selected for that question.

Skipping and returning to earlier questions are not compatible with the logical

methodology of a CAT. The inability to skip questions or go back to change previous

answers will not be a disadvantage to you; you will not fall into that “trap” of

changing a correct answer to an incorrect one with the CAT system.

If you are faced with a question that contains unfamiliar content, you may need to

guess at the answer. There is no penalty for guessing, but you need to make an

educated guess. With most of the questions, the answer will be right there in front of

you. If you need to guess, use your nursing knowledge and clinical experiences to

their fullest extent and all of the test-taking strategies you have practiced in this

review program.

You do not need any computer experience to take this examination. A keyboard

tutorial is provided and administered to all test-takers at the start of the

examination. The tutorial will instruct you on the use of the on-screen optional

calculator, the use of the mouse, and how to record an answer. The tutorial provides

instructions on how to respond to all question types on this examination. This

tutorial is also provided on the NCSBN Web site, and you are encouraged to view

the tutorial when you are preparing for the NCLEX examination. In addition, at the

testing site, a test administrator is present to assist in explaining the use of the

computer to ensure your full understanding of how to proceed.

Development of the Test Plan

The test plan for the NCLEX-RN examination is developed by the NCSBN. The

examination is a national examination; the NCSBN considers the legal scope of

nursing practice as governed by state laws and regulations, including the Nurse

Practice Act, and uses these laws to define the areas on the examination that will