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Assessing student thinking: Exam item writing, blueprinting, and best practices

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Objectives:

Following this offering, participants should be able to:1. Describe the current state of testing in nursing education.2. Discuss the components of testing items that assess critical thinking.3. Demonstrate the development and use of innovative/ alternative in the nursing classroom.4. Identify several ways to develop an exam blueprint in the nursing classroom.5. Describe the components of item and exam analysis.6. Demonstrate selected skills in item writing and blueprinting for use in the nursing classroom.

Overview of testing in nursing education: It’s not what it used to be!

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The purpose of tests…

•Fairness and equity

•Validity and reliability – assessment• Focus on clinical reasoning

• Consistent assessment

•Measure learning (curriculum effectiveness)

•Legal responsibility to prepare competent nurses

•Readiness for licensure/certification

•Other

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Exams

•Our responsibility to provide reliable, valid, and NCLEX® style exams

•The goal is to assess the student for clinical decision-making skills

•Removing bias and unneeded distractions

•To replicate reality whenever possible

•A word about test banks

Think about the good, the bad, and the ugly…

• Good: ideas for test topics, some occasional questions, questions that you can alter to become “yours” and excellent

• Bad: reliance on a test bank heavily or totally, not carefully looking at items before using them in an exam

• Ugly: Just about every textbook test bank can be purchased on the internet. Most of the textbook test banks are updated, but not changed a lot. They may or may not reflect good writing practices or have similarity to NCLEX…

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NCLEX-RN© Test Plan

NCLEX-RN® and

NCLEX-PN®

Focus on

Safe

Practice

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What does NCLEX® Measure?

•Basic knowledge to provide for entry level nursing care

•Ability to set priorities, delegate, interpret data, make decisions, have the knowledge needed to function in a healthcare environment

•Protect the public

•Nursing programs needto prepare students forNCLEX®!

www.NCSBN.org

•Blueprint/Detailed test plans•Domains of nursing practice•Practice analysis•Topics for each area•Questions for topics

•Alternative item tests

•Practice tests

•Test-taking strategies

•Computer adaptive testing

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Test-plan/Blueprint-RN (see PN)

• Safe and effective care environment• Management of care 17-23%• Safety and infection control 9-15%

• Health promotion and maintenance 6-12%• Psychosocial integrity 6-12%

• Physiological integrity• Basic care and comfort 6-12%• Pharmacological/Parenteral Therapies 12-18%• Reduction of risk potential 9-15%• Physiological adaptation 11-17%

NCSBN standards: •Practice analysis-12,000 new RNS

•No changes in blueprint in 2016

•6 Logits harder than 2007

•Level of difficulty– in 2016: maintained changes from 2013

•Innovative items-No set

number—these items

the “realness” of exam

Other changes 2013/2016

•Security issues•Read the beliefs, cognitive levels, and integrated processes•Prescriptions not orders•Anticipate prescription for….

•Client and patient•Pharm-generic names, no trade names•Limited discussion of Nursing Dx•HCP•UAP

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NCLEX-RN® INTEGRATED PROCESSES

•Nursing process—steps•Analysis/not Diagnosis

•Caring

•Communication and

documentation

•Teaching and learning

•NEW-Culture and spirituality

Creating items that REALLY assess critical thinking!

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Cognitive Levels of Test QuestionsEditing Your Test Items

Blooms Taxonomy

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http://www.odu.edu/educ/llschult/blooms_taxonomy.htm

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Knowledge & Comprehension•Knowledge•Recall of facts and specific information•Memorization of specifics• “Define the term diastole”

•Comprehension•Understanding•Ability to describe and explain the material• “Describe the blood flow through the heart”

**Not used on NCLEX® exam**

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Cognitive level-Comprehension

A client with CHF enters the ED. The client is short of breath. The reason a client with CHF has increased work of breathing is because

1. There is increased perfusion of the coronary vessels

2. The client is anxious and is worried about his symptoms

3. There is fluid overload and pulmonary hypertension

4. The clients heart rate decreases and slows circulation of oxygen

Application (Applying) Level Items

• Allows student to demonstrate an understanding of the information.

• Test the ability to not only understand the information, but allows for demonstration of how the information will be used in the situation.

• A nurse is caring for a client with suspected fluid volume deficit. What would the nurse expect the initial vital signs to be?

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Cognitive level-Application

A client enters the ED complaining of SOB, pedal edema, and a productive cough. The chest x-ray shows pleural edema. The nurse would anticipate administering:

1. acetazolamide

2. furosemide

3. hydrochorothiazide

4. triamterene

Analysis Level Items

Requires a breakdown of the

information.

• A nurse is teaching a client with Type 2 diabetes about his regime. His Hgb A1c is 10.5% and FBS this am is 45mm/dl. Which information is critical at this time?

Requires analysis of the

information to determine a

response.

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Cognitive level-analysis

A client enters the ED with the following vital signs: 144-42-132/76-37.3 (98.8). He has crackles in the bases, jugular vein distention, +3 pitting pedal edema, a faint S3, pulse ox of 88%, Pa 02 of 75, CO2 of 66, pH of 7.23, and an increased work of breathing. The nurse would anticipate the following immediate interventions:1. furosemide and O22. NaHCO3 and O23. hydrochlorothiazide and IV fluids4. A beta Blocker and furosemide

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A nurse is caring for 4 patients. After doing rounds and checking all assigned patients, which of the following should the nurse care for first?

1. A client who is ambulatory and to be discharged tomorrow on medications

2. A client who is diaphoretic, restless, and has a fever

3. A client due to physical therapy in two hours and requires medication

4. A postoperative client who received pain medication orally ten minutes ago.

Foundational Recommendations:• 25% of A,B,C, and D (1, 2, 3, & 4) answers

(numbers preferred)• Application level and above• No “all of the following except”• No scenarios or linked questions• Proof reading and formatting• Innovative/Alternative items• Remove as much bias as possible

• Gender neutral• No ethnic information except relevant to question• No proper names• No “complains of”

Steps for writing MC Test Items

1. Identify the content to be tested (blueprint)

2. Write the item stem based on the identified behavior, what do you want the nurse to do?

3. Create the correct option4. Create effective distracters (no LAZY

distracters)5. Provide rationale including references

(optional).

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Multiple Choice Question “parts”•Stem•Provides the problem or question•Should reflect the nursing process

•Options•Distracters: realistic, similar grammar/length •Plausible options – distract from correct answer•Balanced answers

•Correct Answer•Needs to be clearly correct

•Optional: Rationale: Evidence Based! Explain why the right answer is right and the wrong answers are wrong. Reference your statements.

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Basic Principles…

STEM CHECKLIST

•Present tense

•No extra words

•One main idea/focus area

•Asks a clear question

•Absolute terms are gone

•Nursing domain

DISTRACTER CHECKLIST

•Present tense

•No extra words

•One main idea per distracter

•Distracters are constructed similarly and similar length

•Avoid double negatives

Writing Excellent Stems While Being Mindful of NCLEX® Item Style

•All extraneous detail and wordiness are removed

•Refer to the patient as the patient

•Never use trade names on drugs—only generic

•All, every, none, always, never are NEVER used

•NCLEX tests higher level cognitive functions—not knowledge or comprehension—testing policy—early versus later courses

•STEMS are critical part of enhancing question level

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More about great STEMS!•Great Stems don’t ask nursing students to diagnose a

patient (nursing diagnosis=OK; not medical diagnosis)

•Great Stems don’t ask nursing students to prescribe a medication (but may ask about anticipated side effects, complications, drug interactions, interventions, or teaching points)

•Great Stems do focus on challenging nursing action—and can be any part of the nursing process

•Anticipate prescription for…

Great Stems vs. Lousy Stems

Let’s offer a quick critique:

Mrs. Jamison was admitted to the general surgery floor and on admission she did not report having a drinking problem, but she was really alcoholic, and she had drunk 3 gin and tonics prior to admission. The nurse would expect to see the development of what kind of withdrawal symptoms at which point in her hospital stay?

Some great stems…

• What should the nurse do first?

• Which indicates a need for more teaching?

• Which intervention would the nurse anticipate?

• Which client should the nurse assess first?

• Which type of isolation should the nurse implement?

• Which technique of health assessment is most important with this client?

• What would be the most appropriate response?

• What finding would demonstrate an effective intervention?

• What teaching is indicated with this medication?

• What complication would the nurse anticipate with this condition?

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Writing Strong Distracters in NCLEX-RN© Style

•There are no implausible distracters•Each distracter is clear and unambiguous•Each distracter has one focus•There are no “B and D,” “all of the above”•All the answers are about the same length and numbers of characters, and they are constructed similarly (parallel)

Compare and contrast distracters:

Early signs of inadequate oxygenation include:

•Dyspnea

•New onset of apprehension and restlessness

•Cyanosis

•Diaphoresis

The earliest sign of inadequate oxygenation is:

•Dyspnea

•Apprehension

•Cyanosis

•Diaphoresis

Steps for writing MC Test Items

1. Identify the content to be tested (blueprint)

2. Write the item stem based on the identified behavior, what do you want the nurse to do?

3. Create the correct option

4. Create effective distracters (no LAZY distracters—answers stem)

5. Provide rationale including references (optional).

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Apply the Steps

1. Identify the content to be tested• Objective: Perform sterile dressing change• NCLEX Client Needs: Safe and effective care,

reduction of risk potential

2. Write the item stem based on the identified behavior, what do you want the nurse to do?•Utilize principles of sterile technique• Identify steps in performing procedure• Identify steps requiring sterile technique

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Apply the Steps

3. Create the correct option

•Weak:•Maintain sterility when performing sterile dressing change procedure

•Strong:•Do not reach over sterile field when performing sterile dressing change

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Apply the Steps

Create the questionThe nurse is performing a sterile dressing change on a surgical wound. Which nursing action is most important as the nurse is setting up the sterile field?

1. Apply sterile gloves and unwrap the sterile tray.

2. Prevent reaching across the sterile field once it is opened.

3. Keep both hands sterile during the cleansing of the wound.

4. Discard used gauze into the sterile container.

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Apply the Steps1. Identify the content/level/type to be tested

• Objective: Care of the patient with impending respiratory failure.

• NCLEX Client Needs: Health promotion and pharmacology

2. Write the item stem based on the identified behavior, what do you want the nurse to do?• Student needs to recognize the early assessment

changes in an older adult client experiencing respiratory failure and apply appropriate interventions.

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Apply the Steps

3. Create the correct option

•Weak: call respiratory therapy•Strong: deliver nebulized albuterol

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Apply the Steps

Create the question

The nurse is caring for an elderly client with advanced emphysema with air hunger, a respiratory rate of 30, pulse oximetry of 89% and an arterial pH of 7.30. What is the priority action of the nurse?

1. Obtain a Do Not Resuscitate order.

2. Prepare for intubation.

3. Increase O2 to 50% simple mask.

4. Deliver a nebulizer treatment with albuterol.

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Reflect and Evaluate

• Let it sit a couple days, then go back to it….does it still make sense?•Have another faculty review the question.

•Use reasonable goals for revisions: 2 new questions per exam

• Consider using it as a trial question on the exam, gather data on it.

• Item analysis

•Develop testing policy • Percentage of level of difficulty• Use of item analysis• Blueprinting

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Use a checklist, if desired.…

STEM CHECKLIST

•Present tense

•No extra words

•One main idea/focus area

•Asks a clear question

•Absolute terms are gone

•Nursing domain

DISTRACTER CHECKLIST

•Present tense

•No extra words

•One main idea per distracter

•Distracters are constructed similarly and similar length

•Avoid double negatives

Creating innovative/alternative items—In YOUR classroom!

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Current Alternative Items

Multiple Response/select all that applyFill in the BlankHot SpotChart ExhibitDrag and Drop/Ordered Response ItemVideo/Graphic/Audio Interaction

A patient has congestive heart failure and has been taking digoxin for nine years. The patient is admitted with signs and symptoms of digoxin toxicity. Which are associated with digoxin toxicity? (Select all that apply)

1. Bradycardia2. Floaters in the visual field3. Diarrhea4. Digoxin level of 0.4 ng/dl5. Vomiting 6. Yellow halos around lights

Fill in the BlankA nurse is caring for a patient the day following a

major bowel resection. He has a nasogastric tube to

straight drainage. The nurse is calculating the intake

and output for the 8 hour shift.

Orders include: NPO, IV at 120 ml/hour, Irrigate NGT q4h with 50 ml NSS

The patient voided 475 ml and NG drainage for this shift was 120 ml.

What is the patient’s true nasogastric drainage for this 8 hour shift?

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HOT SPOTYou are administering insulin to a client. You are giving 25 Units of NPH with 15 Units of Insulin Regular. To which point on the syringe would you pull back the plunger when you draw up the Insulin NPH? Place an X on the spot.

Chart Exhibit•Exhibit items•Prescriptions

(orders)•H & P• Lab results•Reports• Imaging•Flow Sheets• I & O•MARs•Progress notes•Vital signs

A nurse is changing a dressing on a patient’s subclavian central venous catheter. All of the following steps are important in this procedure. Place them in the correct order of occurrence:

a. Wash hands and don clean gloves

b. Don sterile gloves

c. Apply transparent plastic dressing

d. Clean the site with swabs provides.

e. Secure and label the dressingf. Remove the old dressing and discard

Drag and Drop/Ordered

Response Item

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Graphic Interaction

Video/Audio Interaction

How can I do these with limited technology?

• Have the last exam page or pages be hand graded.

• Or use alternate format strategies that can be done with your scantron sheet.

• Audio or Video clips can be the “first” item on a test, shown to the class all at one time.

• Use ordered response as multiple choice:• 1. 2,3,4,1

• 2. 3,4,1,2

• 3. 4,2,1,3

• 4. 1,3,4,2

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Other issues with alternative items

• Select all that apply• 5 or 6 options

• At least two options

• May be all 5 or 6

• Rank order• 5-6 options

• May not use all available

• Really hard

• Chart exhibit• Several tabs

• To make decision on traditional multiple choice

• New items being developed all the time

• More Realistic

• Take more time

Creating a Blueprint that works for you!

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Test Blue printing

•Content validity

•Develops parameters for course exams

• Identifies concepts to be tested on each exam

• Links to course outcomes/objectives (accountability)

• Identifies % of items based on Bloom’s taxonomy

• Identifies % for each phase of the nursing process

• Links to NCLEX test plan, AACN Essentials, QSEN criteria, program outcomes

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Test Blue Printing Format Sample

•Question(s)

• Chapter

• Topic

• Sub-Topic

• Course Objective

• Blooms Taxonomy

• Cognitive Level

•Nursing Process

•NCLEX Categories

• BSN Essential Outcomes

•QSEN Competency

•Question Type-alternative/innovative55

Developing your blueprint

•Develop you own blueprints

•Questions to consider:•Cognitive level?•Framework?•What courses?•QSEN•Essentials•NCLEX©•Others?

Using item and exam analysis to improve your items!

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Item Analysis •Why is it important?•Determines if grading needs

to be modified for the item.•Provides data measuring

reliability and validity of item.• Identifies weak items that

may need to be eliminated.•Provides feedback for

revisions.

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Keep in Mind the Purpose of Testing

• To promote learning

• To assess learning-to differentiate among learners-how well learning has occurred?

• To gate-keep (more high stakes) to determine whether a student may progress, graduate, or become a nurse

•To incentivize students to study material

Some thoughts….• When using Item Analysis after an exam, students will judge you to

be fair or unfair, reasonable or unreasonable, based on how you respond to the exam.

• Be respectful of students, and clarify that you require a respectful discussion as well.

• If you have made an error or there are a few really bad test items, you may decide to give some credit. Don’t go overboard, or the students may lose confidence in your capacity to write an exam.

• Don’t allow students to push you around in the moment, but also be willing to respond for genuine areas that need a response. “You are making a point about this item that I want to think more about. I will go back and consider your analysis and let the class know.”

• What are some other strategies for dealing with student feedback post exam?

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When Looking at Your Test Statistics…

•Remember that these are a guide for decision-making. Being only a guide, use your own good judgment in a situation.

•Don’t allow yourself to be swayed by a persistent student in the moment…• “Let me respond to all the items (insert when).

I want to think this over carefully.”•Student feedback is valuable, however, and

should be considered along with your statistics.

Look at Your Overall Results First• Mean score (What grade level is this? Do you think it is a good reflection

of performance based on your class? What mean is expected?)

• Standard deviation (How spread out are the scores? Do you believe this is a good reflection of performance? How many A’s, B’s, C’s, and lower do you have?)

• Kuder Richardson (KR 20 or KR 21): this is the overall reliability of your test. The more students taking the test and the more items in the test impacts this statistic—if you are only testing a few students, or only have a few items, the statistic is not very useful.

• What should I aim for in the KR? While this is a judgment, in a faculty written test that is not high stakes with an adequate sample size and number of items, aim for above 0.5.—the goal is to increase this by improving your exam items over time, and it is only one number, not the whole of what matters.

Exam Analysis Strategies

• Item analysis KR20 > .60 (Reliability)• The Kuder Richardson Coefficient of reliability (K-R

20) is used to test the internal reliability of exam questions, to see if the items within the instruments obtained the same results over a population of testing subjects. Range 0 – 1.0.

•Compare teacher made exam results to standardized exams (if used)

•Use results to evaluate curriculum

•Peer feedback

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Item Analysis•Let’s look at total percent correct together:•How many students got the item

correct-percent. •Below about 40% or so—really look at

the item, even for action on these results. •At 100% correct, consider revising for

future tests—too easy.•At or near 0% correct, look for an error

in the key!

3 D’s of Item Analysis

• Difficulty of item• .3-.8 (30% - 80% get it right)• May want some items (mastery items) where more

get it right

• Discrimination • > .25

• Distracters• Each distracter

should a few hits

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Point Biserial Correlation

•Definition: a measure of the association between a continuous variable (the student’s performance on the whole exam) and a binary variable (the student’s performance on that particular test item).

•The Point Biserial can be between -1 and 1. • 0 or no value: everyone got the item right. • Positive values: students who did well on the item also

did well on the test as a whole (“good”). Closer to +1 is better.

• Negative values: students who did well on the item did poorly on the test (“not as good”).Use these findings along with your good judgment about an item to improve your exams over time.

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Using this InformationDecisions

•Keep it•Edit it• Lazy distracter

•Points•Only give credit if they got it right?•Give a point to everyone?•Accept two answers?•Controversial?

•Delete it•Not relevant to key issues

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Put it to work: Creative critical thinking and alternative items

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Steps for writing MC Test Items

1. Identify the content to be tested (blueprint)

2. Write the item stem based on the identified behavior, what do you want the nurse to do?

3. What cognitive level do you want for this question?

4. Create the correct option5. Create effective distracters (no LAZY

distracters)6. Provide rationale including references

(optional).69

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What Level?

Which complication most commonly occurs during the first 24 hours after a percutaneous biopsy of the liver?

1. Nausea and vomiting

2. Hemorrhage

3. Constipation

4. Pain at the biopsy site

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What level?The nurse understands that hemorrhage is a complication of a liver biopsy due to what reason?

1. The liver is rich in arterial and venous blood.

2. There are several large blood vessels near the liver.

3. The test is performed on clients with high liver enzymes.

4. The procedure requires a large piece of tissue to be removed.

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What Level?

Which symptoms observed by the nurse during the first 24 hours after a percutaneous liver biopsy could indicate a complication of the procedure?

1. Pulse 112, blood pressure 100/60, respirations 20.

2. Anorexia, nausea and vomiting.

3. Abdominal distention and discomfort.

4. Pain at the biopsy site.

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Analysis Level

The nurse is caring for a client in liver failure after a percutaneous liver biopsy. The assessment findings include tachycardia, tachypnea and hypotension. The client is lethargic and difficult to arouse. Which prescription would the nurse perform first?

1. Type and cross for 2 units of PRBCs.

2. Apply oxygen at 2L/nasal cannula.

3. Apply pressure to the biopsy site.

4. Place the head of bed flat.

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Create the distracters…

A nurse is caring for a client with suspected fluid volume deficit. What would the nurse expect the initial vital signs to be?1.2.3.4.

Create the distracters

A nurse is teaching an older adult client with diabetes mellitus type 2 about the importance of drinking fluids. Which statement by the client requires immediate follow-up by the nurse?

1.

2.

3.

4.

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Steps for writing MC Test Items

1. Identify the content to be tested (blueprint)

2. Write the item stem based on the identified behavior, what do you want the nurse to do?

3. What cognitive level do you want for this question?

4. Create the correct option

5. Create effective distracters (no LAZY distracters)

6. Provide rationale including references (optional).

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Write your own test question…

•ONE STANDARD ITEM

•Content area: Post-operative care, client teaching, major abdominal survey

•NCLEX® Domain of Nursing Practice: Reduction of risk potential

Write your own test question…

•ONE ALTERNATIVE/INNOVATIVE ITEM

•Content area: Care of a pregnant woman after 24 weeks of pregnancy with proteinuria, hypertension, scomata, and abdominal pain

•NCLEX-RN® Domain of Nursing Practice: Safety

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Practice: Reviewing and critiquing items

•See handout

•Work in pairs

•Critique each item

•Reword to make it:•Application or Analysis Level•Without bias•Parsimony!•Not an opportunity to teach•Clear, objective driven

Put it to work: Enhancing current items to higher level thinking or alternative items

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Making items better at assessing critical thinking Current Exam Question

Your client is a 50 year old male admitted with uremia,

complaining of fatigue, anorexia, diarrhea, joint pain and

pruritus. Physical assessment reveals uremic halitosis,

lethargic and pericardial friction rub. The nurse knows

these uremic symptoms your patient is manifesting are

related to which of the following lab alterations?

1. High BUN and Creatinine

2. High ammonia

3. High potassium

4. Low hematocrit

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Revised Exam Question The nurse is admitting a client with a 10 year history of diabetes and complaints of fatigue, anorexia, diarrhea, and pruritus. Labs include BUN 45 mg/dL; creatinine 4.3 mg/dL; and glucose 179 mg/dL. What are the anticipated initial nursing assessment findings?

1. Recent weight loss, dry hacking cough, increased temperature.

2. Crackles, 3+ pitting edema of the ankles, tachycardia.

3. Disoriented and confused with an irregular heart beat.

4. Cold and clammy skin.

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Current Exam Question

Which of the following diagnostic tests would be used first to evaluate a patient with acute upper GI bleeding?

1. Upper GI series

2. EGD endoscopy

3. Hemoglobin and hematocrit

4. Serum osmolality

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Revised Exam Question

The nurse is caring for an client who has retuned to the unit after an esophagogastroduodenoscopy (EGD) for sclerosis of esophageal varicies. Which assessment finding would be most important for the nurse to report?

1. Blood pressure 148/90, pulse 110 bpm.

2. Hemoglobin of 9.1gm/dL.

3. Nausea and vomiting.

4. Infiltration of the IV site.

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Current Exam Question

A nurse is caring for a client with thrombocytopenia. A potential complication might be:

1. Pneumonia.

2. Myocardial infarction.

3. Gastrointestinal bleeding.

4. Embolic stroke.

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Revised Exam Question

The nurse is caring for a client with a platelet count of 20,000/microliter. Which priority action should be considered?

1. Evaluation of blood pressure every 2 hours.

2. Minimize visitation of relatives.

3. Initiate neutropenic precautions.

4. Hourly neurologic assessment.

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Current Exam Question

A client with Addison’s disease asks the nurse for nutrition and diet advice. Which of the following diet modifications is not recommended?

1. Diet high in grains and fiber.

2. Restricted sodium diet.

3. Diet with adequate caloric intake.

4. High protein diet.

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Revised Exam Question

The nurse is educating a client with Addison's disease about the expected dietary modifications. Which statement by the client would indicate understanding?

1. “I’ll need to stop having a bowl of ice cream each night at bedtime.”

2. “I’ll need to stop sprinkling flax seed on my oatmeal.”

3. “High protein energy bars would not be a good snack.”

4. “I can continue to have canned soups and vegetables for lunch.”

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NOW YOU TRY….A nurse is working with a client who complains of shortness of breath. A nurse provides an intervention. Which of the following best indicates a positive outcome of this intervention?

A. An increase of respiratory rate from 8 to 12 breaths per minute

B. Clear breath sounds upon auscultation

C. A PaO2 of 82 mm

D. A pulse ox of 88%

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Converting items to a higher knowledge levelKnowledge Level Example

What does it mean when the central venous pressure from the distal port of the triple lumen catheter is increased?

1. Heart pressure is increased in the left ventricle.

2. Venous return from the right atrium is increased.3. Pressure within the pulmonary artery is decreased.

4. Workload on the left ventricle is lessened.

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Transforming questions to Application and Analysis levels

• Incorporate the nursing process•Provide options that are all correct and ask for

first action, priority or assessment•Add two or more components that ask the

student to consider context, environment/setting, patient status, disease processes, demographics, or other variables•Ask students to analyze a set of data and generate

a nursing action or priority

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Analysis LevelThe nurse is caring for a client being monitored for central venous pressures. The central venous pressure is 12 mm/Hg. What is the most important nursing assessment based on this reading?1. Lung sounds, pulse oximetry and shortness of

breath.2. Presence of ectopic beats and decreasing cardiac

output.3. Blood pressure and development of peripheral

edema.4. Apical and radial pulse rates.

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NOW YOU TRY…A client is ordered to receive ketorolac. Which of the following client conditions is treated with this medication?

1. Gouty arthritis2. Chronic pain, such as

osteoarthritis3. Post-operative pain4. Rheumatoid arthritis

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Converting items to alternative/ innovative itemsCurrent Alternative: Select AllKnowledge

Which lab abnormalities would be anticipated in a patient with end stage liver failure? Select all that apply.1. Elevated PT and PTT2. Elevated potassium3. Decreased protein and albumin levels4. Decreased ammonia levels5. Decreased liver enzymes

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Revised Alternative: Select all Application

The nurse is assessing a client 24 hours after an acute episode of pulmonary edema. Which findings would suggest an improvement of the cardiac output? Select all that apply.

1. Urinary output of 300 mL over last 8 hours.

2. Blood pressure increasing from 98/58 to 123/69 mmHg.

3. Heart rate decreasing by 23 beats per minute.

4. Lessening of restlessness and disorientation.

5. B-type Natriuretic Peptide (BNP) of 356 µ/dL

6. 3+ pitting edema in lower extremities

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So now it is your turn…with a partner

•Revising items to higher cognitive levels

•Revising items to alternative items

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Make this question a Higher cognitive level

A client with cholelithiasis has the following changes in stools:

1. clay-colored stools with fatty-streaks

2. Hard dark stools with bloody streaks

3. Liquid, yellow stools

4. Black, tarry stools

Make this question a Higher cognitive level

A client received furosemide (Lasix) for symptoms secondary to CHF. Which of the following would best indicate a positive response to this medication?

1. Reduced heart rate2. Elevated specific gravity3. Decrease in blood pressure4. Ease of respirations

Make this Question anAlternative item

A client admitted yesterday with a diagnosis of acute myocardial infarction states they have chest pain. What is the best initial action for the nurse to take:

1. Apply oxygen at 3L/minute via nasal cannula

2. Send a request for a STAT 12-lead EKG

3. Assess pain level every 15 minutes

4. Administer the prescribed analgesic

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Make this Question anAlternative item

A client enters the ED short of breath. He is 83 years old and had an MI 20 years ago. He does not take any meds or follow a special diet. He says that he can not walk up steps without getting “winded,” his feet are swollen, and he needs to sleep with several pillows. Which of the following would the nurse anticipate doing first?

1. Drawing cardiac enzyme levels

2. Doing a 12 lead EKG

3. Assessing weight and comparing to baseline

4. Assessing serum electrolytes

Put it to work: Connecting exam items to a blueprint

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Code Your Questions

•Client Needs area – NCLEX

•Cognitive level – K/C v. A/A

•Nursing Process

•QSEN

•BSN Essentials

•Course objective

•Content area

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A registered nurse is made aware of an IV infiltration by a UAP. The first action of the nurse is to:

A. Ask the UAP to remove the IV

B. Call the physician

C. Assess the IV site

D. Elevate the extremity

A man is running in the park and is witnessed to clutch his chest and fall. A bystander’s first actions should be:

A. Begin mouth to mouth resuscitation

B. Call 911

C. Initiate compressions

D. Open the airway

To determine if a client is experiencing compartment syndrome, which of the following is a priority area for nursing assessment?

1. Assessing for edema at the fracture site2. Palpation of a pulse at the fracture site3. Palpation of pulse distal to the fracture4. Assessing for the presence of drainage on the cast

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Conclusion: Policies and Best PracticesJu

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Classroom Practices for Testing SuccessIt starts with your syllabusYour contract with students

•Expectations•Grading scale•Course requirements•Course logistics•Testing Practices•Also• Late policies•Classroom behavior and

academic dishonesty policies•Academic services

•Refer students to it often! Syllabus QUIZ!

Test Development

•Number of questions-50-80 Questions

•Multiple Choice / Multiple Response•No more than 3 formats on any one exam

• Item Creation / Revision

• Item Analysis Plan / Throw out questions

•Collaborative Testing

•Rationale and Remediation

•Peer Feedback - Teamwork

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Policies: Your expectations• Have a ‘code of conduct’

statement they sign on the front of the exam

• Have the expectations about how the exam will be conducted posted ahead of time, and go over them

• Follow your posted expectations

• Clarify that this is about keeping the testing environment fair for everyone (not that you are being punitive)

During exam

•Do not entertain questions during exam•Distracts others•May be able to “get at” answer•Questions about typos only•Write any question you have on front of exam

Proctored/Paper and Pencil• Being vigilant at all times

• Rules about starting the exam on time.

• Personal items under the chair/at the desk

• Policies about leaving the room during the test

• Keeping the environment quiet

• Taking the exam or answer sheet home/out of the room

• Dealing with transcription errors

• Make Up exam Policies

• Seating charts and alternate versions of the test

• How many minutes per question?

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Proctored Computer Based

• Course-specific software needed to access examinations given online.

• Faculty “tracking”: review number of accesses to tests; access dates/times; duration of time taken to submit a test; whether errors were generated; IP address of computer from which test was accessed.

• Timed assessments – timer issues.

• If the student is not visible to you at all times, how secure is the test? (levels of confidence in terms of test security)

Unsecure Exams: Their Place in Student Learning

Non-proctored online exams are open-book exams in which the faculty can’t know if there is collaboration.

Publicize expectations regarding collaboration or individual achievement (but realize the potential for collaboration & cheating on online work).

These can still have a lot of value for student learning—let’s share some examples.

Thinking Ahead about Make Up Exams

• Giving a “Zero?”• What is an acceptable excuse? • What do your make up exams

look like?• Rules about when/where/how to

make an exam up• Patterns of missing exams

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Exam reviews• Policies• Ensure test security (to prohibit

students from taking electronic or paper copies of exam material out of the review session).

• Make decisions regarding accepting additional answers apart from discussions with students (not during a test review).

• Faculty posttest review may be provided individually or in groups.

• Provide exam reviews AFTER test scoring and item analysis

• If you give exam questions more than one time, security of your questions is important.

• A lot of student learning occurs when students can see and talk through what they missed and why.

• Setting boundaries within which exam review happens can promote civility.

Continuous Improvement in Key

•Develop, follow and update test blueprint

•Review your exams with a critical eye

•Seek feedback from peers

•Be brutally honest with colleagues

•Revise one question at a time

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Test Writing is an Evolutionary Process

•Give yourself permission to not be perfect every time.•Be willing to “listen” to the data from the item analysis and comparison with standardized tests.•Seek and accept feedback.•Allow yourself to grow.•Questions?•Evaluation/Adjournment

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