The NCLEX-RN Exam – Ensuring Knowledge in Today’s Nurses
NCLEX-RN. The initials loom large in the mind of the nursing student – the last hurdle before you become a registered nurse. The National Council Licensure Examination (NCLEX-RN) is meant to protect the public by assuring that a graduate nurse has sufficient knowledge to practice safely. The story of how the NCLEX-RN came to be and what it means in today’s nursing world is very interesting.
NCLEX-RN – The History
While nursing owes a lot to Florence Nightingale, Flo did not believe in licensing exams. She felt that continuing education was the only way to ensure competence over the long run, while a licensing exam simply established knowledge at a particular point in time. Once formal schools of nursing were organized, graduates received a certification of completion, but curriculum varied from one school to another, as did quality and length. Some nursing schools in the late 19th century professed to turn out competent nurses within six weeks!
It wasn’t until 1896 that the American Nursing Association was created; one of the group’s primary goals was to establish nursing licensure. At first, licensing examinations were optional; the idea was to distinguish between the trained nurse and less qualified, unlicensed nurses. Unfortunately, from the public’s point of view, a nurse was a nurse. Most graduate nurses at that time worked in private duty settings with minimal oversight, so the issue of competence was important.
North Carolina enacted the first nursing license exams in 1903 and Virginia followed suit late that year. New York made licensing exams mandatory in 1935, but the law was not strictly enforced until after WWII because of the shortage of nurses. Each state had its own examination until 1944, when the National League for Nursing created the predecessor of the NCLEX-RN exam, the State Board Test Pool Examination (SBTPE). All the states had adopted the SBTPE by 1952, although acceptable passing scores varied from one state to another.
Transition From Paper to Computer
In the days before computers, the the SBTPE and the NCLEX-RN examination were pencil and paper tests. At first, tests were administered at various locations throughout the US and given only twice a year, because of the tremendous administrative issues surrounding paper tests. It could take weeks to months to get the results.
Although the concept of CAT testing was developed early in the 20th century, it really couldn’t be implemented until computers became common and were able to handle the decision-making required to adapt the test to the individual student.
Nursing actually pioneered CAT testing, with development work beginning in the 1980s. The National Council of State Boards of Nursing (NCSBN) conducted many pilot studies from 1986 to 1994, and on April 1, 1994, the first CAT NCLEX-RN exam was launched. It is now used in both the US and Canada.
About CAT Testing
NCLEX-RN is a computer-assisted test (CAT). The first question (which is usually different for each test-taker) is considered to be of medium difficulty. After you answer the first question, an algorithm in the background searches the pool of available questions and selects the optimal question based on the algorithm’s assessment of your ability.
If you answer the second question correctly, the algorithm gives you a third question that is slightly more challenging. Each time you answer correctly, the questions get a little more challenging. If you miss a question, you get a less complex question. The algorithm assures that each person takes a slightly different test that is individualized to his or her skills and knowledge.
One of the great advantages of CAT testing is that the scores are uniform and precise for most test-takers. It also allows the total test time to be shortened, as a candidate who can easily handle challenging questions can quickly prove his or her knowledge with a relatively small pool of questions. However, it also allows the individual who has the knowledge but might struggle in a test environment to take additional time to pass the exam.
Since CAT testing requires a large population sample to ensure new test questions are correctly designed for the majority, the NCLEX-RN always includes some pilot test questions. One disadvantage of CAT testing is that if it has a set time limit as the NCLEX-RN does, it’s difficult for the test-taker to budget his or her time.
However, the six-hour testing period is considered sufficient to determine whether the test-taker has the necessary knowledge. A candidate who runs out of time before answering the maximum number of items may still pass the NCLEX-RN exam. As long as the ability estimate remained above the passing standard for the last 60 items completed, the computer will issue a pass score.
NCLEX-RN Questions and Scoring
The purpose of the NCLEX-RN is to test candidates for the essential abilities, knowledge and skill needed to practice safely at the entry level. Exam questions are not necessarily hard or easy. Once you get several questions into the exam, you have approximately a 50 percent chance of answering each item correctly, because the items are matched to the candidate’s ability. Each candidate gets 15 experimental questions no matter how many he or she answers. You cannot skip questions on the exam. The test format may include fill-in-the-blanks questions, drag-and-drop items or graphics-based topics. You should expect to interpret pictures, table or charts. When the candidate has either passed or failed, the computer will shut off – however, the candidate does not know at that point whether it is a pass or fail.
NCLEX-RN was implemented in 1994. The original test had 750 questions; the total was reduced to 480 in 1982 and 370 in 1983. Today, the candidate is required to answer a minimum of 75 questions; if all the answers are correct, a passing grade is issued. Candidates may answer up to 265 questions before the test shuts off with either a pass or fail grade. Candidates get a maximum of six hours to complete the test, although most finish in less time.
The NCLEX-RN does not have a numerical score; it is pass or fail. The exam is actually scored twice to meet quality control requirements. The computer at the test center performs the first scoring operation and Pearson Vue verifies the results after the test is transmitted. The test results are then released to the relevant state board of nursing, which mails the results to the candidate about one month after the test is taken. Most state boards post results within two or three days after they received them, however, and the candidate can see the results online. The NCSBN also offers a quick results service that costs about $10 and allows the candidate to see the results within 48 hours.
NCLEX-RN Content Areas
The NCLEX-RN has eight main content areas. The four main dimensions of the test are physiological integrity; health promotion and maintenance; safe, effective care environment and psychosocial integrity. Questions relevant to each content area are grouped together and the candidate’s performance is noted as below, near or above the passing standard.
The exam consists of four major categories, two of which also have subcategories. These are:
Safe and Effective Care Environment
- Management of Care – 17-23% of content
- Safety and Infection Control – 9-15% of content
Health Promotion and Maintenance – 6-12% of content
Psychosocial Integrity – 6-12% of content
- Basic Care and Comfort – 6-12% of content
- Pharmacological and Parenteral Therapies – 12-18% of content
- Reduction of Risk Potential – 9-15% of content
- Physiological Adaptation – 11-17% of content
Certain processes are fundamental to the practice of nursing. These threads are woven into the questions and answers on the NCLEX-RN examination.
Nursing Process – an approach to care that is scientific and includes clinical reasoning. The nursing process is sometimes indicated with the acronym AAPIE for assessment, analysis, planning, implementation and evaluation.
Caring – nurses should develop a collaborative environment with the patient that includes mutual respect and trust; the nurse provides compassion, encouragement, hope and support to help the patient meet the identified goals.
Communication and Documentation – this is the old dictum: if it wasn’t documented, it wasn’t done. All verbal and nonverbal interactions, events, and activities associated with patient care, including communication with family and other health care professionals, are recorded.
Teaching/Learning – nurses should help patients acquire the necessary knowledge, skills and attitudes to promote behavior change and should follow such practices themselves to ensure competent care that meets standard of practice guidelines.
Culture and Spirituality – patients have unique and individual preferences based on culture and spiritual practices; the nurse must consider these in his or her interactions and incorporate them into care as long as they do not violate legal practices or the standard of care.
The Application Process
In the last semester of nursing school, academic counselors or instructors usually present an NCLEX-RN information session to help students understand the process and how to apply. Before a nurse can sit for the NCLEX-RN exam, he or she must submit an application for licensure to the relevant state board of nursing.
The next step is to register for the NCLEX-RN with Pearson Vue, the firm that administers the online test. In most cases, the earliest available testing appointment is around three weeks after graduation; the test is offered throughout the year. Person Vue offers over 200 different testing locations in the US and 18 international locations.
A program code (from the school) and email address are required to register. Candidates can also register by phone with Pearson Vue, but it is not recommended due to high call volume. Payment is required at the time of registration.
The test costs $200. The registration remains open for 365 days to allow the state board of nursing to submit the candidate eligibility information. Candidates must take the test within that 365-day window; Pearson Vue will send an Authorization to Test (ATT) email with a range of valid dates for the examination. The candidate must present the ATT email at the time of the examination.
Prepping for the NCLEX-RN Examination
Everyone has their own preferred method of preparing for a major exam like the NCLEX-RN. You’ll find all sorts of resources out there (see list below). There may also be other strategies that will help you ace the test. A study group may offer the advantages of discussion about knotty issues and the opportunity to learn from your peers.
Another advantage of a study group is that each member could buy one of the books (or you might pool your resources to buy several) and share them around. Useful NCLEX-RN review resources include:
- Davis’s Drug Guide for Nurses and Mosby’s Pharmacology Memory Guide – pharmacology is a big issue in nursing. These two tools can help you prepare. If you purchase the Davis book, you’ll also get online resources and a one-year subscription to their online drug guide. Mosby’s focuses on visual learners.
- Kaplan’s NCLEX-RN Premier 2015-2016 – test-taking strategies make a difference in the NCLEX-RN. It’s not a comprehensive review, but it will help you sharpen your test-taking skills. If you didn’t make it with your first NCLEX-RN try, this book contains some good strategies for your second run.
- Kaplan’s NCLEX-RN Content Review Guide – designed primarily as a general review rather than an in-depth study guide, this might be a good choice for the ace student who feels comfortable about his or her knowledge.
- NCLEX-RN Review: Keeping it Real! Simplified (e Book) – designed to help you study on the go, this innovative e Book contains audiovisual material and virtual learning scenarios.
- NCSBN’s Review for the NCLEX-RN & NCLEX-PN Examination – the resource is available through a subscription ranging from three to 15 weeks. The cost ranges from about $50 to $160.
- Prioritization, Delegation and Assignment – delegation skills are vitally important for RNs; roughly one-fifth of the NCLEX-RN questions deal with various aspects of delegation.
- Saunders Comprehensive Review for the NCLEX-RN Examination – to many experts, this is the top-of-the-line NCLEX-RN review resource. It includes a companion CD-ROM and 5,100 practice questions, as well as detailed answers and explanations of the answers. There also a companion book, Saunders Q & A Review for the NCLEX-RN Examination, that is focused on test-taking strategies.
- Live review courses are also available from a variety of sources; do your research, as these may vary in quality and cost.
Before Exam Day
While you’ll want to spend some time studying before the exam, there are some other important activities you should take care of. Create a folder of important documents – you’ll take this with you on exam day. This folder should contains maps and/or directions to the test site. Make sure you know how long it will take to travel, because you must show up on time or you’ll be turned away. Take at least two copies of your ATT email. That way you can be sure you’ll have your identification number. In addition to your ATT, you must provide an acceptable form of photo ID, such as a driver’s license, passport, permanent residence card or military ID. If you have a temporary or permanent disability, make sure you let the test site know well ahead of time for any necessary accommodations.
On Exam Day
It should go without saying that you want to arrive early. Don’t forget to allow extra time for problems like construction, parking or the actual walk to the exam room. You’ll need your ID, but can’t take anything else into the exam room – no writing implements or paper as the test is entirely computer-based. You’ll be provided with an erasable board and pen, and will be able to use an online calculator.
- Cover the basics – don’t cram the night before, get a good night’s sleep instead (and skip the nightcap if you would otherwise have one). Make sure you eat a nutritious breakfast. If you drink coffee or another form of caffeine, don’t go overboard (but don’t skip it – you could trigger a caffeine-withdrawal headache). Although you’ll have scheduled breaks, do go to the bathroom before you enter the exam room.
- Dress in layers – you can’t take a coat, hat or gloves into the exam room. Wear an outfit with removable pieces in case you get hot.
- Don’t schedule anything else on exam day; expect to take the full six hours.
- There’s a tutorial before you start the actual exam; take advantage of the practice.
- Stay focused and relaxed. Use earplugs if you’re easily distracted (the test site staff can usually provide them). Periodically look away from the computer screen or close your eyes and take a few deep breaths. You might get the wrong answer to a question, but if so, don’t agonize over it – let it go and move on.
- Expect hard questions – this test is meant to challenge you.
- Focus on your own performance; someone who finishes early might have failed the exam and been shut down.
- Be sure to let the exam proctors know if you run across a duplicate question; these are considered errors.
In 2016, 150,763 US-educated nurses took the NCLEX-RN for the first time. The majority – 81,657 – were associate degree graduates, although 72,637 had graduated from a baccalaureate program. Only 2,745 had a nursing diploma. Pass rates varied from a high of 87.45 percent in the April to June group to 77.3 percent in the September to December group.
Associate degree nurses had the lowest average pass rate for the year at 81.6 percent. Diploma nurse pass rates averaged 85.39 percent for the year and baccalaureate graduates had an average pass rate of 87.8 percent for the year. The pass rate for repeat test takers educated in the US was 46.14 percent.
Repeating the NCLEX-RN
In most states candidates are allowed to repeat the NCLEX-RN after 45 days if the first attempt resulted in a failing grade. States differ on the number of times a candidate can repeat the exam without required remedial education. Candidates who fail the NCLEX-RN or did not answer at least 75 questions before stopping the examination receive a Candidate Performance Report (CPR).
The CPR is two pages (front/back). The front side explains how CAT testing works. It indicates the number of questions the candidate answered and offers suggestions for how to use the information on the second page. The number of questions answered before the computer shut off indicates how close the candidate was to the passing standard. Candidates who were close to passing are required to answer all 265 questions.
The lower the number of questions, the more likely the candidate’s knowledge was inadequate and performance was farther away from the passing standard. The second page explains the test results. If you don’t pass the first time around, try to determine why.
If you simply didn’t study hard enough, that’s easy to remedy. If it was test anxiety, consider strategies such as learning meditation techniques or mindfulness training before your second attempt.
The NCLEX-RN is the last hurdle you must jump in your journey to become an RN. If you prepare carefully, you’ll leap that hurdle with room to spare. Congratulations, registered nurse – you’re on your way!