Why strategy moves the needle

A large share of items give you four options that are all defensible nursing actions. Nothing about recall separates them; what separates them is order, safety and scope. That is why two candidates with the same content knowledge can score differently — one is reading for “which is correct” and the other for “which is first”.

Work through the list once now, then re-read it after your next practice test with your own wrong answers in front of you. Most of these will map onto a mistake you just made, and that is when they stick.

The 50 strategies

1. If the question asks what the nurse does FIRST and every option looks reasonable, it is asking about order, not correctness. Airway, then breathing, then circulation.
2. An option that sends the problem to someone else is almost never first. Assess, then intervene, then notify.
3. Absolute words – always, never, all, none, must – are usually wrong in an answer option. Nursing rarely deals in absolutes.
4. Two options that say the same thing in different words are both wrong. The answer is one of the other two.
5. When two options are exact opposites, the answer is often one of them. Read those two most carefully.
6. Choose the option that keeps the client safe over the one that keeps the client comfortable.
7. If one option gathers more data and the client is stable, gathering data is usually the answer.
8. The client is always the best source of information about their own symptoms. Ask them before you check the chart.
9. Therapeutic communication answers reflect feelings and stay open-ended. They never give advice, false reassurance or a change of subject.
10. ‘Why’ questions put clients on the defensive. Avoid any option that starts with why.
11. Never pick an option that promises an outcome or says ‘do not worry’. That is false reassurance, not support.
12. Delegation: the registered nurse keeps assessment, evaluation, teaching, and every unstable client.
13. A licensed practical nurse can care for a stable client with a predictable outcome. Anything new, unstable or complex stays with the registered nurse.
14. When choosing which client to see first, look for the one whose finding does not fit their diagnosis.
15. Potassium is never given by IV push. If an option says push, it is wrong.
16. Before giving digoxin, count an apical pulse for a full minute and check the potassium.
17. Hold a beta blocker for a heart rate under 60 or a systolic blood pressure under 100 unless told otherwise.
18. Rinse the mouth after every inhaled corticosteroid dose to prevent oral thrush.
19. Bronchodilator before steroid inhaler: open the airway, then deliver the medication that needs to reach it.
20. A dry, persistent cough on an ACE inhibitor is expected. Angioedema is an emergency.
21. Warfarin follows the INR and is reversed by vitamin K. Heparin follows the aPTT and is reversed by protamine sulfate.
22. Check the platelet count on heparin. A sudden drop suggests heparin-induced thrombocytopenia.
23. Peaked T waves mean high potassium. Flat T waves with U waves mean low potassium.
24. In a blood gas, if pH and CO2 move in opposite directions the cause is respiratory. If pH and bicarbonate move together it is metabolic.
25. Low calcium makes clients twitchy. Look for Chvostek and Trousseau signs.
26. High magnesium wipes out deep tendon reflexes first. That is why you check reflexes hourly on a magnesium infusion.
27. A change in level of consciousness is the earliest sign of rising intracranial pressure. The Cushing triad is late.
28. For autonomic dysreflexia, raise the head of the bed first, then find and remove the trigger.
29. In anaphylaxis, intramuscular epinephrine comes before antihistamines and steroids every time.
30. During a transfusion reaction: stop the blood, run normal saline through new tubing, stay with the client, then notify.
31. Most transfusion reactions happen in the first 15 minutes, which is why the nurse stays at the bedside.
32. A boggy postpartum fundus gets massaged first. A deviated fundus usually means a full bladder.
33. Jaundice in a newborn during the first 24 hours is always pathological.
34. Never delegate what you can EAT: Evaluate, Assess, Teach.
35. Restraints need a time-limited order, never a PRN order, and a quick-release knot on the movable bed frame.
36. C. difficile needs soap and water. Alcohol hand rub does not kill the spores.
37. Airborne precautions: My Chicken Has TB – measles, chickenpox, disseminated herpes zoster, tuberculosis.
38. Neutropenic clients get no fresh flowers, no raw produce and no standing water in the room.
39. For a client on isoniazid, add pyridoxine to prevent peripheral neuropathy.
40. Metformin is held before iodinated contrast and for 48 hours afterwards.
41. Alendronate is taken on rising with a full glass of plain water, and the client stays upright for 30 minutes.
42. Lithium toxicity follows dehydration, low sodium and NSAIDs. Keep salt and fluid intake steady.
43. Fever with muscle rigidity and altered mental status in a client on an antipsychotic is neuroleptic malignant syndrome. Treat it as an emergency.
44. MAO inhibitors need a tyramine-free diet: no aged cheese, cured meat, tap beer or soy sauce.
45. Weight is the most reliable indicator of fluid status. A 1 kg change is about 1 L of fluid.
46. Urine output under 30 mL per hour in an adult is reportable.
47. In the case study items, read the exhibit tabs before the options. The abnormal finding is usually the key to the answer.
48. On select-all-that-apply items, judge each option as a separate true or false statement. Do not look for a pattern.
49. For ordered response, place the obvious first and last steps, then sequence the middle.
50. If you have narrowed it to two, pick the option that is broader, safer and does not require an order.

15 facts to memorise outright

Strategy will not rescue you on these. They are single-answer recall items that show up across every category, so they are the cheapest marks on the paper.

More NCLEX practice and review

Everything on this site tagged NCLEX lives in the NCLEX category.

Sources

• NCSBN — NCLEX Test Plans (official blueprint and category weights)
• NCSBN — The NCLEX examination (official candidate information)