How to Solve a Difficult NCLEX Question

Do you feel stuck when you encounter a difficult question as you study for your NCLEX? Do you feel overwhelmed by the information that’s presented? And unsure again, when you consider the options? Do you sometimes wonder if you even attended nursing school?

Take a deep breath. You are definitely not alone. We’re here to help.

NCLEX is more than memorization

NCLEX is meant to determine if you are able to provide safe and effective care as a new nurse. Its purpose is to ensure public safety. Although it’s essential to be familiar with basic knowledge such as vital signs, common laboratory values, and drug calculations, the bulk of the exam is intended to evaluate your ability to use critical analysis and judgment to recognize cues, prevent complications, and assess outcomes. Client safety is ALWAYS the foundation of your decisions.

In 2023 NCLEX was updated to include more test items that use the NCSBN Clinical Judgement Measurement Model. All candidates will now be presented with 6-part Evolving (Ongoing) Case Studies that simulate real situations nurses might encounter in their daily practice. (RN candidates will have three Case Studies; LPN candidates will have two.)

Let’s solve a difficult NCLEX question together

Nurse Plus offers practice test items that are similar to those you’ll find when you sit for your NCLEX. That means some of them are challenging…and they’re meant to be. But when you’re able to break down the components of the questions, you can find the answer.

Below is an actual practice question that stumps many Nurse Plus subscribers. We receive frequent comments about this test item; often we’re asked to rewrite it, because it’s too “confusing.” It’s actually a great example of what to look for in an actual NCLEX question—and why clinical thinking is crucial.

Here’s the entire question:

When admitting a client with cardiac tamponade, which finding will be consistent with the diagnosis?

Possible Answers:

​1. Hypertension

​2. Abdominal pain

​3. ​Tachypnea

4. Distended neck veins

Step 1: Study the stem

The stem can provide important clues that can point directly to the solution. Focus only on what data is provided. Pay attention!

You are told that the client has a diagnosis of cardiac tamponade. What do you already know about this condition?

• Fluid accumulates in the pericardium, the sac surrounding the heart.
• The fluid compresses the heart, preventing it from pumping effectively.
• If the heart can’t pump, stroke volume and cardiac output are reduced.
• Venous circulation is backed up, causing venous congestion. Jugular venous pressure becomes elevated.

Step 2: Find the distractors

In a standard multiple-choice test item, there is one correct answer, called the “key.” All the other options are called distractors.

Distractors are meant to evaluate your understanding of the question and your ability to differentiate between the key and other options that appear to be plausible. Good distractors literally “distract” candidates who haven’t learned the material or are simply guessing. Find out more about the “Anatomy of an NCLEX Question” here.

A few tips:

1. Look for an obvious wrong option and eliminate it.
2. Find two similar distractors—they can’t both be the key.
3. Avoid a general option and choose the one with a specific focus.
4. Check if the option has some incorrect information.

Consider the options for this test item

Question: When admitting a client with cardiac tamponade, which finding will be consistent with the diagnosis?

Let’s analyze each option and find the distractors:

​1. Hypertension: Distractor.. Cardiac tamponade causes hypotension because pressure in the pericardium prevents the heart from filling, resulting in a decreased cardiac output and a drop in blood pressure.

​2. Abdominal pain: Distractor. Although it’s rare, abdominal pain can occur, due to liver congestion. However, abdominal pain is a vague complaint for many conditions and is not specific to cardiac tamponade.

​3. Tachypnea: Distractor. This is the distractor Nurse Plus gets the most comments on. While rapid breathing is observed in cardiac tamponade, it is NOT a hallmark sign. When the heart is unable to pump efficiently, oxygen can’t reach organs and tissues. Tachypnea is a compensatory measure. Tachypnea is a general sign present in many other conditions, such as pneumonia, asthma, pulmonary embolism, diabetic ketoacidosis, anaphylaxis, and sepsis. NCLEX candidates who select this option are not familiar with the pathophysiology of cardiac tamponade.

4. Distended neck veins: Key. Classic signs of cardiac tamponade include distended jugular veins, hypotension, and muffled heart sounds—known as Beck’s Triad.

Nurse Plus subscribers get a hint and an explanation

When you learn how to analyze a test item, you’re on your way to a successful NCLEX. When studying for your examination, Nurse Plus helps when you feel unsure about an answer.

We provide a hint to remind you of a basic principle. It’s intended to nudge your memory or ability to reason the correct answer.

​Hint:

​Blood flow to the heart is reduced.

We also give a brief explanation as a review. It also helps you decide if you need to return to your nursing notes or find more information on a topic.

Explanation:

Distended neck veins, due to rising venous pressures, are a hallmark sign of cardiac tamponade. Cardiac tamponade is usually the result of penetration of the pericardium, the thin, double-walled sac surrounding the heart. When blood or other bodily fluids enter the sac and compress your heart, blood return to the heart is severely restricted. Other signs include hypotension, anxiety, restlessness, tachycardia with muffled heart sounds, tachypnea, dyspnea, and chest pain that radiates to the neck, shoulders, and back.

Keep practicing and preparing

As you study for your NCLEX, notice which questions are hardest for you. Spend extra time on those subjects—everyone has at least one area of nursing that’s challenging. Take as many practice tests and NCLEX Simulator tests as you can.

Read the stems of the test items carefully. Everything you need to select the key is there. Consider the options and get rid of the obvious distractors. Use your critical judgment skills. Sure, you need to memorize some facts. But the rest? You’ve got this!