Becoming a Nurse: Licensure

Temporary Permits

Some states allow first-time licensure applicants to work as a graduate nurse (GN). To do this, you may request a temporary permit to practice nursing. The permit is issued on approval of the completed licensure application. Permits are nonrenewable, last for about 90 days to six months (depending on the state where the permit is obtained), and expire when a nursing license is either approved by passing the NCLEX examination or when a nursing license is disapproved due to failing the NCLEX exam. To be eligible for a temporary permit, applicants must have never failed the NCLEX exam and never failed to appear and take the exam.

Temporary permits allow graduate nurses to practice under the direct supervision of a currently licensed registered nurse who is physically present in the facility and accessible to designate or prescribe a course of action when performing complex or advanced skills. Graduate nurses working under temporary permits must notify their employer immediately upon notice of failure to pass the NLCEX exam or licensure disapproval.

The Licensure Exam

State and territorial boards of nursing regulate nursing practice and help to ensure public safety by requiring that candidates for nursing licensure pass an examination that measures the competencies needed to perform safely and effectively as an entry-level nurse. Once a license is issued, the board of nursing continues to monitor the nurse's compliance with state laws and takes action against those nurses who exhibit unsafe nursing practice.

Each state determines membership of their board of nursing, but most include a mix of registered nurses, licensed practical nurses, advanced practice nurses, and consumers, all of whom were appointed to their positions. The boards of nursing in all 50 states, the District of Columbia, Guam, the Virgin Islands, American Samoa, and the Northern Mariana Islands make up the membership of the National Council of State Boards of Nursing (NCSBN).

The NCBSN has two licensure examinations that are used by state and territorial boards of nursing to assist them in making licensure decisions. These exams are the National Council Licensure Examination for Practical Nurses (NCLEX-PN) and the National Council Licensure Examination for Registered Nurses (NCLEX-RN). The NCLEX exams test knowledge, skills, and abilities for the safe and effective practice of nursing at the entry level. The NCLEX exams are administered by Computer Adaptive Testing (CAT). You take the exam on a computer, but you do not have to have computer skills to take it. The exam comes with a tutorial that demonstrates how to use the mouse and the on-screen calculator, how to record your answers, and the various question formats. One the exam begins, you will be able to request assistance on how to use the computer.

Persons diagnosed as having a disability and who require special testing accommodations may submit a "Request for Reasonable Testing Accommodations" form and appropriate documentation.

Since the NCLEX is a computerized test, it is true that not everyone gets the same test. Each of your test items is specifically chosen for you based on the answer you give to the previous question. The test program gives you questions with the degree of difficulty based on your ability, and it continues to do this until it becomes apparent that your ability is either above or below the passing standard. Therefore, some candidates may complete the minimum number of questions and pass, while others complete the minimum and fail—the computer shuts off the test once it is evident whether you pass or fail.

Based on your ability level, you may receive anywhere from 75 to 265 questions with a six-hour maximum time period for completion for the NCLEX-RN, or 85 to 205 questions within a five-hour maximum for the NCLEX-PN. Try to give yourself about one minute per question to keep within the time limit—you will be used to this because most of your nursing program exams were developed with that time frame in mind. The computer allows you two prescheduled breaks over the five/six hours. You may take these breaks or opt out. The test ends when you answered enough questions to show that you passed or failed, completed the maximum number of questions, or reached the maximum time. You pass if you demonstrate that you achieve a competence measure above the passing standard. You do not pass if you achieve a competence measure below the passing standard or if you answer fewer than the required minimum number of questions before the maximum time expires.

NCLEX questions appear one at a time. You can spend as much time as you like on each (keeping that 5/6 hour maximum in mind), but you cannot backtrack to previous questions. You can also change your answer until you confirm your answer to move on to the next question.

You will need your critical thinking cap to take NCLEX, as the majority of items (questions) are written in a manner targeted to the higher levels of cognitive function. That means you will be asked to apply, analyze, synthesize, and evaluate. Essentially, you will need to know what to do in given situations. Make sure you read the question carefully and that you do not add your own information to it.

The content focuses on client needs: management of care, safety, infection control, health promotion and maintenance, basic care and comfort, pharmacological and parenteral therapies, reduction of risk potential, physiological adaptation, and psychological integrity. There are some content differences between the NCLEX-RN and the NCLEX-PN. The NCLEX-RN will expect RN candidates to prioritize patients and to assign tasks to practical nurses and nursing assistants, while the NCLEX-PN will expect LPN candidates to request more assistance from registered nurses and to assign tasks to nursing assistants.

Most test items are traditional four-option, multiple choice questions. But alternative items may include multiple answers (multiple choice questions that require the licensure candidate to select one or more responses), fill-in-the-blanks, and items that require the test-taker to identify an area on a picture or graphic (sometimes called "hot spots"). All item formats may include graphics, tables, or charts.

Four-option multiple choice items contain the stem (question) and four answer choices. You choose only one of the options.

A -year-old child is hospitalized with a fractured femur and placed in a full body cast. In the plan of care, the nurse should include developmental enhancing activities that include:

1. building a tower with blocks
2. collecting dolls or toy cars
3. noisy pull toys
4. puppets for a puppet show

The correct answer is d. A three-and-one-half-year-old child is a preschooler, and preschoolers require imaginative play to enhance their development. When choosing diversional activities for children, think development as well as diagnosis. A child in a full body cast will not be able to run around and play!

Multiple answer items contain a stem and a list of possible answers. For these you may choose as many options that you find appropriate.

A patient with chronic obstructive pulmonary disease (COPD) has been receiving oxygen therapy for an extended time. The nurse suspects that the patient is experiencing oxygen toxicity as evidenced by:

substernal discomfort
paresthesia
malaise
fatigue
dyspnea
restlessness

The correct response for this question is to choose all of these answers because all of them are signs of oxygen toxicity. Oxygen is essential for life, but certain clients can develop oxygen toxicity if exposed to high concentrations for a brief period of time or low concentration over a prolonged period of time. Read multiple answer items carefully because one, some, or all of the answers may be correct.

Fill-in-the-blank questions require you to type in your response. Many of these are dosage calculation items that test both your math and formula skills.

The nurse needs to administer Amoxicillin 250 mg. Amoxicillin comes in 500 mg per 5 ml. The nurse should administer _____ ml.

The correct answer is 2.5ml.
500 mg = 5ml. The nurse needs to administer 250 mg.
Cross multiply 500/5ml : 250/x
500x = 1,250 = 1,250/500 = 2.5

Dosage calculation questions are common on NCLEX—and exams throughout your nursing program because it is critical that you know how to accurately calculate medication doses to help avoid medication errors. There are several ways to come to the correct answer. Use the method you were taught in your nursing program.

"Hot spots" may contain a diagram and a question that asks you to click on the part of the diagram that corresponds to your question. For example, you may be shown a diagram of a heart and asked to click on the spot that represents the most common congenital heart defect in children. In order to answer this, you would need to know that the most common defect is ventricular septal defect, and you would need to know where in the heart that defect is located (between the two ventricles).

The exam is comprehensive, so you may have a question about a depressed 80-year-old in heart failure, followed by one about a pregnant woman with diabetes mellitus, and then one about a six-year-old child with hemophilia and a sudden headache. As you may have noticed, the questions are integrated; each one tests your knowledge on more than one concept. Remember to carefully read the question but not "read into it." You need to answer the question on the computer screen, not the one you may be creating in your head.

Everything you need to know about NCLEX, including the NCLEX-PN and NCLEX-RN Test Plans and Candidate Bulletin can be found at: www.ncsb.org.

If you can graduate from a nursing program, you can pass NCLEX. Think positive—and prepare.

Preparing for the NCLEX Exam

Passing NCLEX is the rite of passage to your new career. Passing puts the RN or LPN after your name. Passing gives you the nursing salary you studied hard for. Not passing delays employment as a licensed nurse, creates loss of income, and can even result in low self-esteem. One study of nursing graduates who failed the NCLEX-RN showed several themes: carrying failure as a daily burden, losing their identity of being a nurse, doubting past accomplishments, seeing themselves as damaged goods, wanting support, and not daring to hope. These graduates said they felt cut off from the community of students and faculty who had been important to them while in their nursing program.

Passing NCLEX takes preparation that begins on your first day of your nursing program, so make sure to make use of the tips you learned in Chapter 3, as well as the suggestions noted here to help pass NCLEX. There is no magic formula for passing, and everyone has their own individual needs. Some nursing graduates need intensive preparation, while others need just a quick review. Most need something in between the two extremes.

1. Take ownership of your career. While others may help you, it ultimately remains up to you to pass NCLEX.
2. Plan to take the test as soon after graduation as possible, while all that information is still fresh in your mind. Studies show that early completion of NCLEX increases the chances of success; so the longer you wait the less likely it is that you will pass on your first try.
3. Focus. NCLEX focuses on safety, decision making, and prioritizing—much less than the fountain of knowledge you poured into your head throughout your nursing program. Therefore, this is the one time you want to focus on just what is on the test.
4. Study. NCLEX focuses on safety, decision making and prioritizing—not on everything you learned in school. Therefore, this is the one time you want to focus on just what is on the test. Whether you use self-study books, an online program, a live course, or the plan mandated by your nursing program, you need to brush up on content and test-taking skills. There is a cornucopia of available NCLEX-prep programs, most of which focus on the NCLEX-RN, so choose wisely. When in doubt, ask your nursing instructors for assistance in making the right choice for you. NLCEX-prep programs do add an extra cost to your nursing education costs; however, the price of failing NCLEX can be significantly higher. If you have financial difficulties, consider creating a NCLEX piggy bank when you begin your nursing education or asking for a NCLEX-prep program as a graduation gift.
   1. Self-study books: Several publishers and individual companies sell books designed to help you pass NCLEX. Be sure to choose one (or more) that is current (check the copyright date), include content, and have NCLEX style questions with rationales. Their questions should contain several alternative format questions for you to practice, as well as the rationales as to why the right answer is correct, and why all the other options are not.
   2. Online programs: These vary from strictly question-and-answer to programs with content video streaming. You may want to choose a comprehensive program that gives you content, questions with rationales, and test-taking skills, or, if you have not had much experience answering computerized questions, you may at least want to consider using a supplemental program that improves your ability to answer computerized questions.
   3. Live classes: Colleges and private companies offer NCLEX-prep courses that vary from 30 to 48 hours. When investigating a course, find out if: their faculty are experienced nurses or nurse educators; they include content, practice questions, and test-taking skills; and if they offer a refund or a free program should you not be successful taking the NCLEX exam.
5. Develop a study plan. Pull out your calendar and mark off the days until you take your exam, then schedule your study time. Don't be overly ambitious; be realistic, especially if you are going to work full-time and/or care for a family, and don't cram in study right before the exam. Instead, plan to relax and revitalize the day before the exam.
6. Use your stress management skills. Eat right. Exercise regularly. Get adequate rest and sleep.
7. Manage your test anxiety by following steps 1 through 6 and step 8. You may also want to try deep breathing and other relaxation techniques, but if your test anxiety level has frequently interfered with your ability to pass previous exams, you may want to talk to your healthcare provider or your school counselor for a more individualized plan.
8. Maintain a positive attitude
   1. Post signs around your home and car that say, "I will pass NCLEX."
   2. Write your name with the letters LPN or RN after it.

Copy the sign below and fill in your name and appropriate title:

Taking the NCLEX Exam

Most nursing programs help you apply for licensure and the NCLEX exam because they care about their students and because they might lose their accreditation if they have continuously low pass rates. Besides offering assistance in test-taking skills, most help you with your licensure and NCLEX applications.

There are five steps and they are relatively simple:

Getting Licensed in Another State

While the NCLEX exams are national, each state has its own licensure requirements. Therefore, you need to obtain licensure in your new state if you move. Begin by contacting the state board of nursing in your new state and asking them about their licensure requirements. Your new employer may also help you get your new license. You may need to take additional courses, but your new employer or state board of nursing can help you obtain those, too.

Once licensed in another state, you may opt to keep your original license. You can maintain licensure in multiple states as long as you continue to meet each state's requirements for license renewal.

The NCSBN has a program called the Nurse Licensure Compact (NLC) that allows nurses to have one license in their state of residency and to practice in other states, subject to each state's practice law and regulation. In order to practice across states under one license, you must legally reside in a NLC state to be eligible to have a multistate license. As of December 2008, participating states included: Arizona, Arkansas, Colorado, Delaware, Idaho, Iowa, Kentucky, Maine, Maryland, Mississippi, Nebraska, New Hampshire, New Mexico, North Carolina, North Dakota, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, and Wisconsin. If your state is not listed, check with your state board of nursing to see if has since joined NLC.

Renewing Your License

Most states require you to renew your nursing license every two to three years. Licensing boards usually send renewal notices prior to the expiration date of your license; however, failure to receive a renewal notice does not relieve you of the responsibility for renewing your license before the expiration date.

Renewal typically requires that you complete an application form and pay a fee. You will most likely again be asked about any criminal convictions and chemical dependencies that may have occurred since you were licensed, and you will also most likely be asked if there is or was any malpractice litigation against you. Many states now also require that you complete a minimum of mandatory continuing education hours to renew your license.