Using NCLEX-style questioning during theory discussion to prepare students for clinical application

By Diana Rupert, PhD, RN, CNE

During any nursing program, preparing nursing students to “think like a nurse" is a tough task that needs to be completed in a relatively short time. Helping students to understand the clinical applications of nursing theory content provides a key step forward in accomplishing this goal and assists students to foster their clinical reasoning skills. A concrete way that faculty can establish the link between theory and application is to use NCLEX-style questions during classroom experiences and discussions.

Students come to nursing programs with different life experiences and various contacts with nursing activities. For example, they may have interacted with nurses at young ages while volunteering at hospitals or working at healthcare clubs. It is also not unusual to hear that family members have inspired a student's interest in nursing or a television show sparked curiosity about the profession. In such cases, students likely have had some exposure to clinical experiences in the nursing field. Other students start their nursing programs having already obtained licensure (e.g., licensed practical/vocational nurse) or other types of health care certification (e.g., nursing assistant). They, too, also will have familiarity with the kinds of scenarios or experiences likely to be encountered during clinical practice.

While experiences in and with nursing are helpful for orienting students and providing a baseline of familiarity with the profession, often we caution students to be careful in using past experiences as the basis for clinical reasoning. Many in practice find “short cuts" that facilitate care, but this may not necessarily follow the best nursing practice available. The items in the NCLEX are designed to focus on ideal practice, which is not always what the nurse will experience in reality. This is where nurses must use their clinical reasoning skills. Nursing schools cannot prepare students for every situation in which they may find themselves.

Many nursing curricula begin clinical experiences within the first nursing course. Students have instruction in theory content in a classroom setting and are required to relate the content to actual nursing situations. On occasion, nurse educators offer personal experiences highlighting a situation and clinical reasoning. Still, there can be disconnects in many content areas.

One way to assist students in application of knowledge is by interjecting NCLEX-style questions when teaching the theory content. Because of the nature of NCLEX-style questions, these questions fit perfectly as a teaching strategy. The nurse educator must first understand the unique format of writing NCLEX-style questions, as opposed to knowledge-based content questions. Characteristics of appropriately written NCLEX-style questions include the following:

• A nurse and a client in a clinical situation/scenario
• A nursing action stem followed by plausible nursing distractors

Faculty benefits of using pertinent NCLEX-style questions in the theory setting include the following:

• Uses clinical reasoning by allowing students the opportunity to place themselves in the role of the nurse, drawing from the theory content
• Can incorporate laboratory values, medications, and diagnostic studies into question stem and distractors
• Provides an opportunity for decision-making in leadership and delegation
• Emphasizes question levels of application, analysis, and evaluation
• Allows faculty to gauge student understanding of the content

When incorporating questioning into the classroom presentation, the nurse can frame the situation to focus on the need to understand the nursing responsibilities. By teaching this way, the nurse instructor fuses NCLEX preparation with clinical application. For example, in a Fundamentals of Nursing class, the instructor may discuss the history and pathophysiology of the client needing an elastic bandage, explain the procedure of applying the elastic bandage, and then have the students practice that skill. This is common and sound teaching strategy. By adding a clinical reasoning component, however, the instructor includes a new dimension, possibly one that students have not yet encountered and that requires them to take their base of knowledge and clinically reason about what to do next. The instructor can posit a scenario in which a client needs an elastic bandage for first aid, and the nurse notes that the client has dependent edema increasing throughout the day. The questioning may then be, “How would the nurse best maintain the elastic bandage in this situation?" or “At which point would the nurse anticipate the elastic bandage needing rewrapped?" or even “What clinical manifestations would determine the need for the elastic bandage to be rewrapped?"

The chart below provides a variety of content areas and NCLEX-style questioning that can be associated.

Student benefits of answering pertinent NCLEX-style questions include the following:

• Testing the student's knowledge base
• Placing the student in a clinical scenario
• Encouraging content discussion and addressing any “muddy" points
• Preparing the students for NCLEX-style questions on the unit examination and licensure examination
• Improving clinical reasoning skills
• Increasing student engagement in the classroom
• Exposing students to potential nursing scenarios that they may experience within the clinical setting
• Increasing student confidence in their clinical reasoning abilities

Faculty can place NCLEX-style questions within a PowerPoint or similar application and display them using an overhead projector. The nurse educator can verbally state the questions or assign them for students to discuss in small group settings. Linking theory to the clinical setting enhances nursing education and success in theory and on the clinical unit.