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HealthDecember 29, 2020

Strategies to help nursing students become successful test takers

By: Diane M. Billings, Ed.D, RN, ANEF, FAAN
Knowing how to take and pass tests is one of the most important skills a nursing student can acquire. Nursing students take tests to determine admission to the nursing program, measure attainment of course learning outcomes, assess readiness for progression and graduation, and, ultimately to become licensed.

Nurse educators can prepare students to take these tests by not only helping the students learn the content, but also develop a process they can use to answer teacher-made and commercially available tests, as well as to prepare for the licensing exam. In this blog, you will learn about the reasons why students have difficulty answering test questions correctly, and strategies you can use to help your students develop the metacognitive skills for understanding the test-taking process required to become a successful test taker.

Nursing tests, unlike most tests in liberal arts and sciences courses, have a unique structure, require students to use a variety of test item formats, depend on student’s understanding of a specialized vocabulary and are written at higher levels of the cognitive domain. Thus, requiring students to apply information rather than memorize it for quick retrieval. Preparing students for taking nursing tests is particularly important at the beginning of the curriculum when students transition from taking tests that primarily require recall of knowledge and understanding, and then during each nursing course and after students have taken each test. Helping students developing test-taking skills has assumed additional importance as faculty prepare students to take the new test item formats being implemented by the National Council of State Boards of Nursing (NCSBN) licensing exam (NCSBN.org). Preparing students involves understanding why students do not choose the correct answer and then using strategies to help them develop effective test-taking skills.

Reasons why students do not answer test questions correctly

There are a variety of reasons why students do not answer test questions correctly. These include 1) inadequate preparation; 2) not knowing how to “parse” the question; 3) being distracted or anxious during the test; and 4) guessing or changing answers.

Inadequate preparation. Students may not prepare for a test because they lack study skills or do not estimate the time it will take to study. Some students “cram” and memorize facts, approaches that are insufficient for answering nursing test questions that require the student to apply, analyze, evaluate, and create.

Inability to “parse” the structure and format of the question. Questions on nursing tests have a particular structure and format. The structure includes three components: the scenario, the stem/question and answer(s). Also, nursing test questions use a variety of formats, for example, multiple-choice, multiple response, drag and drop, and, starting in 2023, new “Next Gen” formats such as extended drag and drop, cloze, enhanced hot spot and matrix that require students to respond to data from a patient history, electronic record, or laboratory report and identify cues, draw conclusions, make plans, take action and evaluate outcomes. Students must be able to recognize both the item structure as well as the format and how to navigate each when answering the question.

Another reason students may not answer a question is that they do not understand what the question is asking, or they may not read the question carefully, particularly if they are at the end of the test and pressed for time to complete. Students may read into the question or understand the question from a perspective that is not intended in the question. Also, some students may not understand the keywords in the scenario, question, or overlook directions for answering the question such as “first”, “priority”, or “in correct order”. Students for whom English is not their first or only language, are at particular risk for not understanding the words in the question or the cultural meaning of a question.

Being distracted, anxious, or not pacing themselves. Another factor that can influence students’ success on a test is being distracted because of disruptions in the testing environment or because they are worried about issues in their personal life. Attention span during a test tends to peak at about 45 minutes (Wiles, 2015), and some students, and particularly those who have been diagnosed with an attention deficit disorder or anxiety disorder, may not be able to maintain their focus during tests that last much more than one hour. For longer tests, students should have an opportunity to take a break.

While many students have “test anxiety” and can learn to use anxiety reduction strategies such as deep breathing, there is an increasing number of nursing students who have been diagnosed with health problems such as Attention Deficit Disorder and Anxiety Disorder. These students may require accommodations for testing. Students who do not manage their anxiety are more likely to become distracted, lose focus and change their answers (George, Juller, & Bartz, 2016).

Student’s exam scores can also be affected by not pacing themselves when answering questions throughout the exam (Thomas & Baker, 2011). If students spend too much time on several questions, they may not be able to finish the exam or resort to wild guessing at the end of the test and unnecessarily lose points.

Guessing or changing answers. Before taking any test, the student should know if there is a penalty for guessing. Most nursing tests do not have a penalty for guessing, and thus, students should make a guess. Students have a better chance of answering the question correctly when they can make an informed guess or can eliminate several incorrect answers.

Students may risk making an error by changing an answer. Changing answer from incorrect to correct only improves the answer 50% of the time (George, Juller, & Bartz, 2016), and students who are anxious or are not well prepared tend to change their answers more often. If students recognize that they have made a mistake and change the answer are likely to answer the item correctly (Frank, 2020).

Faculty can help students manage each of these factors by orienting the students to taking tests at the beginning of the curriculum, in each course prior to taking an exam, during the course by using ungraded practice test questions and when returning the test to the student for review. Each of these moments offer opportunities to teach students how to develop the metacognitive strategies required to be a successful test-taker.

Teaching students to learn test-taking skills before they take a test: Test-taking readiness assessment

There are several strategies faculty can use to help students be successful test-takers before they administer a test. One strategy is to conduct an orientation to test-taking at the beginning of the program, and/or at the beginning of each course. The session could include a discussion and demonstration using several types of test questions to teach the students about.

  1. The structure of a question on a nursing test: the scenario, question (stem), answers.
  2. The cognitive function required to answer the question (apply knowledge; analyze data; evaluate, or create).
  3. The nursing action needed (develop a teaching plan/care plan; interact with the health care team; give a report, calculate a drug dose/IV drip rate).
  4. The step and type of a critical thinking, nursing process, or clinical judgment model to use to answer the question (assess/recognize cues, form a hypothesis/make a nursing diagnosis, etc.), use a management process (delegate, communicate).
  5. Basing an answer on best nursing practices.
  6. How to select the correct answer; guessing; changing answers.
  7. Strategies to manage distraction, anxiety, pacing.

Strategies to use as class preparation and during class

Faculty can offer students opportunities to take ungraded, self-directed practice tests. For example, faculty can, using a learning management system, offer an ungraded pretest/practice test before students come to class. Students can also be directed to use test questions that are included in ancillary materials that accompany a textbook. During class, faculty can embed practice questions in PowerPoint slides after each “teaching segment”/ “theory burst” and help the students parse the question and determine the correct answer. Faculty can also take advantage of teaching/learning technology such as polling and interactive software such as Padlet or Jam Board to provide students an opportunity to practice and receive feedback while working alone or in groups to solve case studies. To ensure that students are not only learning and practicing the application of content, faculty can ask the student to use a test-taking readiness questionnaire when they are taking practice tests, using questions from test review books or using online tests. (See Figure 1, Test-taking Readiness Questionnaire which you can adapt for your specific needs).

Figure 1: Test-taking readiness questionnaire

  1. I understand the structure of a test question: I can identify relevant and irrelevant information in the scenario; when I read the question, I understand what the question asking and how the question relates to information in the scenario and information from sources such as the electronic health record, nurses notes, a prescription, or lab reports.
  2. I can identify the type/format of a question and the best strategy to use when answering this type of question.
  3. I can recognize the cognitive function required to answer the question (know and apply information; analyze data from various sources; evaluate outcomes of care; or create a shift report, teaching plan, or staffing plan.
  4. I understand the process to use to answer the question such as the steps of a clinical judgment process, and can establish priorities for patient care.
  5. I can use anxiety management and time management strategies that work for me.
  6. I understand when I should guess or change an answer.

Teaching students to improve test-taking skills after they take the test: Exam wrappers

Faculty also have an opportunity to help students improve their test-taking skills after they take a test. Typically, faculty conduct a post-exam review with students, with the entire class, in a small group or by appointment. Unless structured carefully, these test reviews can end up with students challenging answers to earn more points, rather than having students focus on why they did not answer the question correctly. Using exam wrappers can change the focus of the review session from challenging a question to developing test-taking skills.

An exam wrapper is a structured questionnaire used by students to identify which factors influenced how they answered the question. The goal of using exam wrappers is to help students develop metacognitive skills to improve their test-taking abilities (Schuler & Chung, 2019). When using an exam wrapper, students identify the strengths and limitations of their test-preparation strategies; reflect on the link between exam preparation and their test score; identify patterns and reasons for incorrect answers and determine changes they can make in their approach to preparing for the test and answering the questions correctly. (See Figure 2 for an example of an exam wrapper which you can adapt for your specific needs).

Although faculty can use the exam wrapper in a variety of ways, here is one approach. To use an exam wrapper, students bring the exam wrapper to the test review session. While maintaining exam security, students review their scored test and answer the questionnaire. Faculty can then guide the students to self-reflect, discuss with a peer, or invite the student to meet individually for further discussion. When working with a group of students, the entire process should take about 10 minutes. To maintain exam security, faculty can collect the exam wrappers and the test at the end of the review session.

Post exam reviews with students using exam wrappers also give faculty an opportunity to discuss the content of questions which most students answered incorrectly and suggest strategies that would help students answer a particular type of question. Exam wrappers are most effective when they are used consistently across the course and curriculum as students develop their metacognitive skills for test-taking. The emphasis is on what the student did to prepare for the test, the types of mistakes they made, strategies that may be more effective, and how they will prepare differently for the next test.

Figure 2: Exam wrapper

Which questions did you miss?

For each question you missed, note the reason why.

Preparing for the exam

  1. I did not spend enough time preparing for this test.
  2. I did not use effective study strategies to answer this type of question; I can recognize a pattern in the reasons I did not score well on this test.
  3. I did not know enough of the content to answer the question.
  4. Understanding the structure and format of the question

  5. I did not understand the structure of the question; I did not identify significant information in the scenario; I misread the question; I did not read the options carefully.
  6. I did not understand the format of the question (multiple-choice, multiple response, drag and drop, cloz, etc.) and how to respond to this type of question.
  7. I did not understand what this question was asking (identify priority, collaborate/communicate with team, make a care plan; use a process such as a clinical judgment process or nursing process; follow a sequence of steps in order).
  8. I did not understand the words used in the question.
  9. Being distracted, anxious, not allowing enough time to answer all questions

  10. I was distracted during the test.
  11. I was anxious and unable to concentrate.
  12. I spent too much time on some questions and did not finish the test.
  13. Guessing, changing answers

  14. I guessed or made careless mistakes.
  15. I changed answers.
  16. I needed more time to answer the questions.

How will you prepare differently for the next test?

There are many reasons why students have difficulty taking nursing exams. While lack of preparation may be the most common, other reasons include not understanding the structure and format of the test question, being distracted or anxious during the test, or guessing or changing the answer. Tests in nursing schools have unique properties and faculty can use strategies to teach students how to take these tests before they take the test, and then as the students’ review their own test, faculty can help students develop the metacognitive skills that will increase the students’ likelihood of being effective test-takers.

Diane M. Billings, Ed.D, RN, ANEF, FAAN
Expert Insights Contributor for Wolters Kluwer, Nursing Education
  1. Frank, T. (2020). Should You Change Answers on Multiple-Choice Tests, or “Stick With Your Gut?” College Info Geek. Retrieved October, 26, 2020 from https://collegeinfogeek.com/changing-answers-on-tests/
  2. George, T. M., Mulller, A. & Bartz, J. (2016). A mixed-methods study of prelicensure nursing students changing answers on multiple choice examinations. Journal of Nursing Education, 55 (4), 220-223.
  3. National Council of State Boards of Nursing, NGN for Educators. Retrieved October 26, 2020 from https://www.ncsbn.org/11447.htm
  4. Schuler, M. S. & Chung, J. (2019). Exam wrapper use and metacognition in a fundamentals course: perceptions and reality. Journal of Nursing Education, 58, 7, 417-421.
  5. Thomas, M. H. & Baker, S.S, (2011). NCLEX-RN: Evidence-based strategies. Nurse Educator, 36 (6) 246-249. Wiles, L. L. (2015). “Why can’t I pass exams?” Providing individualized feedback for nursing students. Journal of Nursing Education, 54(3 Suppl.). S 55-S58.
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