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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. 1 3/5/2013 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 2 3/5/2013 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 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 3 3/5/2013 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………… 4 3/5/2013 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 5 3/5/2013 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 6 3/5/2013 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. 7 3/5/2013 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. 8 3/5/2013 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 9 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. 10