Download CREATING ALTERNATE FORMAT ITEMS

3/5/2013
Session Objectives:
CREATING ALTERNATE FORMAT
ITEMS:
WHY, WHEN, & HOW

WHY?
 Compare
alternate item format recognized by NCLEX-
RN®

WHEN?
 Discuss

strategies for the use of alternate item formats.
HOW?
 Discuss
approaches for creating critical thinking
alternate format items.
Jean Flick, MS, RN
Conflict of Interest Disclosure

Elsevier Testing: Contract item writer
2013 NCLEX® Examination
Candidate Bulletin states:
Candidates may be administered multiple choice items as well
as items written in alternate formats.
These formats may include but are not limited to:
multiple response
fill-in-the-blank calculation
ordered response, and/or
hot spots.
All item types may include multimedia such as charts, tables,
graphics, sound and video.
NCSBN website FAQs


An alternate item format is an examination item
that uses a format other than standard, fouroption, multiple-choice items to assess
candidate ability.
 Alternate item formats may include:






Multiple-response items that require a candidate to select one or
more than one response;
Fill-in-the-blank items that require a candidate to type in number(s)
in a calculation item;
Hot spot items that ask a candidate to identify one or more area (s)
on a picture or graphic;
Chart/exhibit format where candidates will be presented with a
problem and will need to read the information in the chart/exhibit
to answer the problem;
Ordered Response items that require a candidate to rank order or
move options to provide the correct answer;
Audio item format where the candidate is presented an audio clip
and uses headphones to listen and select the option that applies;
and
Graphic Options that present the candidate with graphics instead of
text for the answer options and they will be required to select the
appropriate graphic answer.
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Building on the Basics
THIS IS GREAT STUFF!!!!!

Creating test items:
 Bloom’s
Taxonomy
Model of Critical Thinking Test Items
 Morrison’s

Preparing a valid exam:
 Nursing
program curriculum & testing policy
Test Blueprint
 NCLEX-RN®

Ensuring exam reliability:
 Basic
Test Item Analysis
Morrison’s Model for
Critical Thinking Test Items




Bloom’ s Taxonomy
New Bloom’s
Taxonomy
NCLEX-RN® Test Blueprint 2013
Percentage of Items from Each Client Needs
Category/Subcategory
Safe and Effective Care Environment
Management of Care 17-23%
Safety and Infection Control 9-15%
Heath Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 12-18%
Reduction of Risk Potential 9-15%
Physiological Adaptation 11-17%
Are written at the application or higher cognitive
level
Require multilogical thinking
Require a high level of discrimination to choose from
among plausible alternatives
Include a written rationale
From: “Critical Thinking and Test Item Writing, 2nd ed., Morrison,
Nibert & Flick, 2006, HESI.
3-Step Method of Item Analysis
1. Review
Difficulty Level
2. Review Discrimination Data
Point Biserial Correlation Coefficient
(PBCC)
3. Review Effectiveness of Alternatives
Response Frequencies
Non-distracters
From www.ncsbn.org
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Standards of Acceptance

Item Difficulty
30 – 90%
So…..back to alternate formats….

Why?




PBCC
Nursing PBCC
0.20 and above
0.15 and above

Good practice before NCLEX-RN®
Best testing
When?
Classroom practice
Internal exams
 External exams




KR20
Nursing KR20
0.70 and above
0.60 and above

How?


Selecting a test item format:
When does a nurse…






Use a calculated numeric value
Select a specific location
Collect data from an audible source
Choose from multiple options
Plan a sequence of actions/interventions
Make decisions based on multiple types of data
Hot spot: Select a location
Fill-in-the-blank:
Calculated numeric values



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


Image from Wold, “Basic Geriatric Nursing, 4th ed.”

Medication doses
IV infusion rates
Intake and output measurements
Calorie counts/nutritional analysis
Packs per day
Using graphics in test items

Hot spot format
Multiple choice format or other alternate formats
Graphics may be images or photos

Graphic from Paul & Hebra, “The nurse’s guide to cardiac rhythm interpretation”

Physical assessment
Data analysis
Skill performance

Adapt current MC items
Create new items

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Original test item

A.
B.
C.
D.
When pumping up the cuff to measure a client’s
blood pressure, the nurse observes Trousseau’s sign.
What serum laboratory value should the nurse
monitor in response to this finding?
Glucose.
Calcium.
White blood cell count.
Platelet count.
Convert to graphic
When pumping up the cuff to measure a client’s
blood pressure, the nurse observes a change in the
client’s hand position, as seen in this image. What
serum laboratory value should the nurse monitor in
response to this finding?

A.
B.
C.
D.
Glucose.
Calcium.
White blood cell count.
Platelet count.
Image from Matteson and McGonnell, “Gerontologic Nursing, 3rd ed”.
Original test item

The nurse needs to administer 1.5 mL of medication.
Which syringe should the nurse select?
The nurse needs to
administer 1.5 mL of
medication. Which syringe
should the nurse select?
A
B




A.
B.
C.
D.
TB syringe.
3 mL syringe.
5 mL syringe.
10 mL syringe.
C
D
Graphics adapted from Macklin, Chernecky and
Infortuna, “Math for Clinical Practice.”
Collect and use data from an audible
source



Breath sounds
Heart sounds
Bowel sounds
Multiple choice/multiple response
(MCMR)







Collect data: The nurse recognizes (this sound)
as….
Use data: After auscultating (this sound) in (this
context), what action should the nurse take (first)?





Assessment data/techniques
Medication side effects
Supplies needed for a procedure
Client teaching
Nursing actions
Laboratory results
Risk factors/risk reduction
Staffing assignments
Interdisciplinary team involvement
Etc, etc, etc…………
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
A male client with Parkinson’s Disease is taking
levadopa-carbidopa (Sinemet). What actions
should the nurse take to determine if the medication
is effective? (Select all that apply)
A.
B.
C.
D.
E.

Observe the client while he ambulates.
Auscultate the client’s bowel sounds.
Measure the client’s oxygen saturation.
Watch the client perform self-care measures.
Ask the client to rate his level of pain.
The nurse is giving report to the oncoming shift about a
client who is receiving treatment for hyperglycemic
hyperosmolar syndrome (HHS). It is most important for
the nurse to provide current data about which serum lab
test results? (Select all that apply)
A.
B.
C.
D.
E.

Platelets.
Potassium.
Amylase.
Hemoglobin.
Glucose.
A newly hired unlicensed assistive personnel (UAP)
at an acute care facility is assigned to assist the
nurse in caring for a client with diabetes mellitus.
The nurse should confirm the UAP’s ability to
perform which skills? (Select all that apply)

A hospice client’s care plan includes the diagnosis
“Feeding self-care deficit related to hand tremors and
dysphagia.” In planning an interdisciplinary team meeting
to address the goal of increased independence in self
care, which team members are important for the nurse to
include? (Select all that apply)
A.
B.
C.
D.
E.
The nurse notes that a client has a PRN prescription
for glucagon. Which assessment findings may
indicate the need to administer the medication?
(Select all that apply)
A. Slurred speech.
B. Hypertension.
C. Frequent urination of dilute urine.
D. Abnormal sensations in the feet.
E. Unsteady gait.

Ordered response



A. Use of a toenail clipper to trim toenails.
B. Administration of sliding scale insulin.
C. Obtaining a capillary blood sample.
D. Teach the client how to count carbohydrates.
E. Use of a glucometer to measure glucose.
Physical therapist.
Occupational therapist.
Speech therapist.
Social worker.
Home health aide.


Normal physiology
Pathophysiologic sequalae
Progression of signs & symptoms
Skill performance
Sequence of activities that require
multilogical thinking
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Traditional MC

A.
B.
C.
D.
Which action should the nurse complete first when
implementing these prescriptions for a client newly
admitted with urosepsis?







Prescriptions (Dr’s order sheet)
Nurses’ notes
Medication Administration Record (MAR)
Laboratory values
Vital sign graphics
Pain scale
Fall risk
Pressure ulcer risk
In which sequence should the nurse implement the
prescriptions for a client newly admitted with urosepsis?

A.
B.
C.
D.
Administer initial dose of an IV antibiotic.
Obtain a urine specimen for culture.
Schedule peak & trough levels with the lab.
Insert an indwelling urinary catheter.
Chart/exhibit
Choose from multiple sources of data

Convert MC to Ordered Response
Administer initial dose of an IV antibiotic.
Obtain a urine specimen for culture.
Schedule peak & trough levels with the lab.
Insert an indwelling urinary catheter.
Sequence: D-B-A-C
Admission prescriptions
Admission assessment
S: Extreme fatigue
Obtain soft regular diet Feels hungry & thirsty
NS w 20 mEq KCl at 75 Recent 8 lb weight loss
ml/hr
Administer Prostigmine PO O: Dry mucous membranes
Inelastic skin turgor
Dietary referral for teaching
Breath sounds CTA
Admission lab reports
Na 145.0
K 3.2
Cl
102.0
Hct 55%
Hgb 10.0
WBC 10,000
Albumin 2.2
The ED nurse assumes care of a client with myasthenia gravis. After reviewing the medical record, in which sequence should the nurse complete the admission prescriptions?
A.
B.
C.
D.
Obtain soft regular diet
NS w 20 mEq KCL at 75 ml/hr
Administer Prostigmine PO
Dietary referral for teaching
B‐C‐A‐D
Topic: C & S specimen collection from an indwelling
urinary catheter
Just for fun….


Select topic/concept to be tested
Identify key points
 Include


a management perspective
Identify which alternate format BEST tests each key
point
Write new item/adapt current item

Key points:
 Why
is it done? Suspected infection
is it done? Asepsis; fresh urine
 When is it done? Before 1st dose of antibiotic
 Management perspectives:
 How
 Assign/delegate
task to UAP/PN
instruction to UAP
 Supervise correct technique
 Provide
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Traditional knowledge level MC Item:





What is the purpose of obtaining a urine specimen
for culture and sensitivity?

Check for infection.
Measure fluid status.
Assess renal function.
Determine pregnancy status.
Hot Spot

Critical Thinking
Multiple Choice
The nurse is planning to obtain a urine specimen
for a culture and sensitivity test from a client’s
indwelling urinary catheter. From what location
should the specimen be obtained?
The nurse is preparing to obtain a urine specimen for
culture and sensitivity from a client’s catheter and notices
that the urine in the drainage bag is dark amber and
cloudy with a foul odor. What action should the nurse
take first?
A.
B.
C.
D.
Determine the client’s white blood cell count.
Notify the healthcare provider of the findings.
Review the medications the client is receiving.
Clamp the catheter to collect urine in the tubing.
Multiple response multiple choice

To obtain a specimen for culture and sensitivity from a
client’s indwelling urinary catheter, what supplies
should the nurse bring to the client’s room? (Select all
that apply)
A. 10 ml syringe.
B. Sterile gloves.
C. Biohazard specimen bag.
D. Alcohol wipes.
E. Tape.
F. Sterile saline.
Ordered Response

The nurse prepares to obtain a urine specimen for culture and
sensitivity from a client’s urinary catheter and observes that the
client’s urine is dark amber and cloudy with a foul odor. In
what sequence should the following actions be implemented by
the nurse?
A.
B.
C.
D.
Remove exam gloves.
Clamp the urinary catheter.
Administer a newly prescribed antibiotic.
Access the specimen port with a sterile syringe.
MC using Charts
Vital signs graphic
Day 1 99.4-88-14-110/60
Day 2 99.8-90-16-112/64
Day 3 102-96-18-118/70
Lab tests
Day 1 WBC 6500/mm3
Day 2 WBC 8500/mm3
Day 3 WBC 12,000/mm3
Fluid balance flow Sheet
Day 1 I = 800 ml O = 750ml
Day 2 I = 800 ml O = 700 ml
Day 3 I = 850 ml O = 700 ml
The nurse plans to obtain a urine sample for culture and sensitivity
from a client’s catheter and reviews the client data shown above.
Before notifying the healthcare provider of the data, which action
should the nurse implement?
A. Clamp the catheter and obtain a specimen.
B. Increase the client’s intravenous fluid rate.
B-D-A-C
C. Hold the next scheduled dose of antibiotic.
D. Replace the catheter with a new one.
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Topic: A positive Battle’s sign is consistent with a
basilar skull fracture
Management

The charge nurse observes a practical nurse (PN) emptying a
client’s urinary catheter drainage bag into a specimen cup.
The PN states the specimen is to be sent to the lab for culture
and sensitivity. What action should the charge nurse
implement?
A. Remind the PN to place the specimen cup in a biohazard
transport bag.
B. Observe the color and appearance of the specimen obtained
by the PN.
C. Advise the PN to discard the specimen and obtain a specimen
from the port.
D. Assign the PN to another task and ask an RN to obtain another
specimen.

How to assess for Battle’s sign
What does it signify
 What to do if present
 Management perspectives:


Patient assignments
Patient acuity/transfers
Delegation of tasks/assessment

Traditional multiple choice

A.
B.
C.
D.
Which format will best test the key points?
Critical Thinking Multiple Choice
A client has a positive Battle’s sign. What does this
signify to the nurse?

Probable head trauma.
Impending sepsis.
Abdominal injuries.
Risk for liver damage.
Hot Spot

Key points:
In assessing a client
who experienced a
contra coup head
injury, the nurse
documents the
presence of a positive
Battle’s sign after
observing what area?
The nurse assesses a trauma victim. The client has
VS of 101F-92-22-108/70 and has a positive
Battle’s sign. What assessment should the nurse
complete first?
A.
B.
C.
D.
Measure pupillary response to light.
Palpate and auscultate abdomen.
Check for apical-radial pulse deficit.
Assess degree of skin elasticity.
Multiple Response

The nurse assesses that a trauma victim exhibits a
positive Battle’s sign. Which actions should the nurse
implement? (Select all that apply)
A.
B.
C.
D.
E.
Cover the site with a sterile dressing.
Splint the area surrounding the injury.
Determine the Glascow Coma Scale score.
Monitor the pupillary response to light.
Assess for the presence of a carotid bruit.
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Management
Ordered response
Which client can most safely be transferred from the
critical care unit to a medical-surgical unit?

A.
B.
C.
D.
Three days following a carotid endarterectomy, a client has
an inflamed incision.
A client with a positive Battle’s sign develops otorrhea and
a fever of 102º F.
One week following a spinal cord injury, a client complains
of a headache.
Four days following a CVA, a client has bilateral coarse
lung crackles.
Chart/exhibit
The school nurse is called to the gymnasium where a
child was injured and is now lying on the ground. The
nurse immediately observes a large bruise behind the
child’s left ear. In which sequence should further
assessment be completed by the nurse?
 A. Determine respiratory rate and pattern.
 B. Observe arms and legs for more bruising.
 C. Note responsiveness to commands.
 D. Assess for hearing loss in the left ear.
A-C-B-D

Chart/exhibit continued

Vital signs
Assessment Data
Diagnostic test results
0800:
99.2F-88-16-120/80
O2 sat 97%
GCS 14
Pain scale 2
0900:
99.8F-80-14-130/70
O2 sat 96%
GCS 12
Pain scale 3
Retrograde amnesia about
injury
Lethargic, c/o mild head
pain
Positive Battle’s sign
Moves all extremities
Breath sounds clear
Respirations non-labored
Skin warm dry, elastic
WBC
RBC
Hgb
Hct
Na
K
8,000
4.8
13
42%
147
3.8




Testing is Teaching


Try to include the nurse in every question
Rationales provide a means for students to see the
critical thinking process of the test item writer
 If
the rationale is “just because”, the test item is
probably not a critical-thinking level test item.

Every word matters
 What
the nurse does first, is, in reality, not always the
highest priority!!
 A nurse never does nothing!!

The nurse assumes care of an adult female trauma
victim and reviews the client’s electronic health
record as shown above. Based on the available
information in the medical record, which nursing
action takes priority?
A. Initiate sepsis care bundle protocol
B. Prepare for insertion of ICP catheter
C. Insert indwelling urinary catheter
D. Transfuse one unit of packed red blood cells
Health Care Disparities: Practice Item






The nurse is most concerned about health care disparities for which
group of clients?
(Test taking hint: re-word the question in your mind: Which group is
least likely to receive health care equivalent to all other persons?)
A. A group of mentally challenged adults of various ethnic groups
who work for Goodwill & live in a supervised group home.
B. A group of elderly Caucasian widows who reside in the same
long term care facility and meet weekly for support.
C. A group of African-American high school drop-outs who are
attending GED classes as part of a probation program.
D. A group of young adult Chinese women who live together and
who were victims of human trafficking.
Keep it real
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3/5/2013
Rationale:



Health care disparity occurs when access to health care services is
unequal, as compared to others. There is a high risk for limited care
opportunities for (D) because this group of persons have no
apparent resources or support system and have already been
victimized. (A, B, and C) have support systems and resources to help
gain access to health care services.
Resources: Lewis ethical dilemma boxes, classroom discussion and
presentation.
This item addresses lecture objective 2 and is written at the
comprehension level. It requires knowledge related to risk potential
and evidence-based practice, and reflects the nurse using
assessment and analytical skills, acting within the role of member of
the healthcare team.
Rationale:



An ethical dilemma occurs when two values are in conflict. In (B), the
nurse is faced with the choice between the client’s need for access to
care (beneficience) and the potential of placing other clients at risk
because of failure to take an antibiotic for a communicable infection
(nonmaleficience). (A, C, and D) may cause harm to the individual
patient, but are less likely to present an ethical dilemma to the
nurse.
Resources: Lewis ethical dilemma boxes, classroom discussion and
presentation.
This item addresses lecture objectives 1 and 2 and is written at the
synthesis level. It requires knowledge related to risk potential,
pharmacology, evidence-based practice, and reflects the nurse’s use
of analytical skills while acting in the role of patient safety
advocate.
Patient Adherence: Practice item

Several elderly clients live in a group home setting with shared
meals and household responsibilities. A nurse visits the clients
regularly to ensure compliance with prescribed medical regimens,
which is required to continue to live in the home. In which situation is
the nurse most likely to be faced with an ethical dilemma?
A.
B.
C.
D.
A client with a UTI stops taking phenazopyridine (Pyridium).
A client with a DVT stops taking warfarin (Coumadin).
A client with cancer stops taking tamoxifine (Volvadex).
A client with a giardia infection stops taking metronidazole
(Flagyl)
Testing is Teaching


Try to include the nurse in every question
Rationales provide a means for students to see the
critical thinking process of the test item writer
 If
the rationale is “just because”, the test item is
probably not a critical-thinking level test item.

Every word matters
 What
the nurse does first, is, in reality, not always the
highest priority!!
 A nurse never does nothing!!

Keep it real
References



2013 NCLEX® Examination Candidate Bulletin,
www.ncsbn.org
Alternate item formats: FAQ,
www.ncsbn.org
“Critical Thinking and Test Item Writing, 2nd ed.”
Morrision, Susan; Nibert, Ainslie; and Flick, Jean
HESI, Inc. 2006.
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