Example:

A 6 yr. old girl with a fractured femur is brought to the ER by her parents. When asked how the injury occurred, her parents state that she fell off the sofa. On examination, the nurse finds several lesions on the child’s buttock. Which of the following statements most appropriately reflects how the nurse should document these findings?

1.  Read the question stem carefully.

2.  Pay attention to the adjectives. "Most appropriately" tells you that you need to select the best answer.

3.  Reword the question stem in your own words. In this case, it is: "What is the best charting for this situation?"

A 47 year old male construction worker is admitted to the hospital for treatment of active tuberculosis. The nurse teaches the patient about tuberculosis. Which statement, if made by the patient, would indicate to the nurse that further teaching is necessary?

1. Read the question stem carefully.

2.  Look for hints. Pay particular attention to the statement "further teaching is necessary". You are looking for negative information.

3.  Reword the question stem in your own words. In this case, it is: "What is incorrect information about tuberculosis?"

• Sixth senses don’t work!!! – do not answer questions based on feelings or hunches.
• Do not look for a specific answer choice….eliminate wrong answers. If you eliminate three answer choices, the fourth answer choice must be the correct answer.
• No second chances! Eliminate only what you know is wrong. However, once you eliminate an answer choice, do not retrieve it for consideration. You may be tempted to do this if you do not feel comfortable with the one answer choice that is left. Resist the impulse!
• Do not focus on unnecessary information. Focus on the question, not the background information.

DON’T PREDICT ANSWERS

Don’t look for the "ideal" answer choice that your expecting.

Example:

The nurse describes the procedure for collecting a clean-catch urine for culture and sensitivity to a male patient. Which of the following explanations, if made by the nurse, would be most accurate?

A.  "The urinary meatus is cleansed with an iodine solution and then a urinary drainage catheter is inserted to obtain urine."
B.   " You will be asked to empty your bladder one half hour before the test; you ill then be asked to void into a container."
C.  "Before voiding, the urinary meatus is cleansed with an iodine solution and urine is voided into a sterile container; the container must not touch the penis."
D.  "You must void a few drips of urine, then stop; then void the remaining urine into a clean container, which should be immediately covered."

Reworded question: "What is true about a clean-catch urine specimen for culture and senstivity?"

Correct answer is letter C. Many students will select letter D because they see the expected words ""Void a few drops; stop; continue voiding." Be careful. This question is a good example of why scanning for expected words could get you into trouble. You may see expected words in an answer choice that is not correct. (remember sterile specimen is needed for C/S test….using just a clean container is incorrect)

USE MASLOW’S NEEDS TO ESTABLISH PRIORITIES

Because physiological needs are necessary for survival, they have highest priority and must be met first. If you don’t have oxygen to breathe or food to eat, you really don’t care if you have stable psychosocial relationships!!!

Example:

The nurse plans care for a 14 year old girl admitted with eating disorder. On admission, the girl weighs 82 lbs. And is 5’4" tall. Lab test indicate severe hypokalemia, anemia and dehydration. The nurse should give which of the following nursing diagnoses the highest priority?

A.  Body image disturbance related to weight loss
B.   Self-esteem disturbance related to feelings of inadequacy
C.  Altered nutrition: less than body requirements related to decreased intake
D.  Decreased cardiac output related to the potential for dysrhythmias

1.  Look at the answer choices. If the answer choices are both physical and psychosocial, eliminate all psychosocial answer choices. (physiological needs must be met first) … meaning, eliminate choice A and B.

2.  Consider the remaining answer choices (C and D). Does the choice make sense with regard to the disease or situation as described in the question?

3.  Can you apply ABC’s (airway, breathing, circulation)? If ABC does not apply, what is the highest priority?

Letter C makes sense since the patient is anorexic and is 5’4" tall and weighs 82 lbs.
Letter D makes sense since dysrhythmias are a concern for a patient with severe hypokalemia, which often occurs with anorexia.

Correct answer: Letter D – decreased cardiac output is higher priority than altered nutrition.

A woman is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled. Preoperatively, which of the following goals is most important for the nurse to include on the patient’s plan of care?

A.  fluid replacement
B.  pain relief
C.  emotional support
D.  respiratory therapy

Correct answer : letter A

Options B and C are eliminated because they are psychosocial in nature (in the NCLEX, pain is considered a psychosocial problem)

Letter A – fluid replacement makes sense since a ruptured fallopian tube causes extensive bleeding in the abdominal cavity

Letter D – does not make sense; an obstetrical patient is not likely to need respiratory care prior to surgery

ASSESSMENT vs. IMPLEMENTATION

Assessment is the first step in the nursing process and take priority over all other steps. It is essential that you complete the assessment phase of the nursing process before you implement nursing activities. Don’t implement before you assess!!!

Example:

A 10 year old boy was riding his bike to school when he hit the curb. The boy tells the school nurse, "I think my leg is broken." What is the first action the nurse should take?

A.  Immobilize the affected limb with a splint and ask patient not to move
B.  Ask the client to explain what happened
C.  Put the client in semi-Fowler’s position to facilitate breathing
D.  Check the appearance of the client’s leg

Determine whether you should assess or implement. The client has stated "my leg is broken" but this is NOT the nurse’s assessment. Eliminate options A and C because they are implementations.

Correct answer: Letter D – assessment of the leg takes priority over an assessment of what happened to cause the accident.

A 12 year old boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert, conscious but in severe pain with a possible fracture of the right femur. What is the first action that the nurse should take?

A.  immobilize the affected limb with a splint and ask him not to move
B.  make a thorough assessment of the circumstances surrounding the accident
C.  put him in semi-fowler’s position to facilitate breathing
D.   check the pedal pulse and blanching sign in both legs

Determine whether you should be assessing or implementing. According to the question, the nurse has determined that the boy has a possible fracture. This implies that assessment has been done and it is time to implement. Eliminate options B and D because they are assessments.

Correct answer: Letter A – the situation does not indicate any respiratory distress, so letter C is eliminated. Use the ABC’s if they are appropriate to the situation.

SAFETY – includes meeting basic needs (oxygen, food, fluids, etc.), reducing hazards that cause injury to patient (accidents, obstacles in the home), and decreasing thetransmission of pathogens (immunization, sanitation).

DECIDE WHAT WILL CAUSE THE LEAST AMOUNT OF HARM.

Example:

A 4 year old child undergoes a tonsillectomy for treatment of chronic tonsillitis unresponsive to antibiotic therapy. After surgery, the child is brought tot he recovery room. Which of the following actions should the nurse include in his plan of care?

A.  institute measures to minimize crying
B.  perform postural drainage every two hours
C.  cough and deep breathe every hour
D.  give ice cream as tolerated

1.  Reworded question: What should you do after tonsillectomy?
2.  Are all answer choices implementations?…..yes.
3.  If you are still not sure of your answer, ask yourself: "What will cause my patient the least amount of harm?"

A.  will help prevent bleeding….consider this
B.  may cause bleeding….eliminate
C.  may cause bleeding…eliminate
D.  may cause child to clear his throat causing bleeding….eliminate

Correct Answer: letter A

Priorities are important in deciding which nursing care to give. To help select correct answers, think:

• Maslow
• The Nursing Process
• Safety

DO EVERYTHING BY THE BOOK – use your real world experience to help you visualize the patient described in the question, BUT SELECT YOUR ANSWERS BASED ON WHAT IS FOUND IN THE TEXTBOOKS.

Example:

A 36 year old woman sustains a fractures left femur in a car accident. She is placed in balanced suspension skeletal traction using a Thomas splint and a Pearson attachment. The patient tells the nurse that she has "terrible" pain in her left thigh. Initially, the nurse should:

A.  determine that all the weights and ropes from the traction apparatus are in line and hanging free
B.  ask the patient for more information about the location and characteristics of the pain
C.  check the splint and Pearson attachment to make sure they are appropriately positioned
D.  explain to the patient she is experiencing in the affected leg a common occurrence

Correct Answer: letter B (The nurse should focus on assessing the patient and her problem before assessing the function of the equipment. All complaints of pain must be thoroughly investigated by the nurse.)

A.  This answer has you checking the equipment , not the patient. Your first concern must be the patient, not the traction
C.  same as letter A
D. Any complaints of pain are considered abnormal and should be thoroughly investigated by the nurse.

Example:

A 66 year old woman is admitted to the hospital with flu-like symptoms. When taking the history the nurse learns that the patient has been taking Lanoxin (Digoxin) 0.125 mg PO daily and furosemide (Lasix) 40 mg PO daily for the three years. Last month her physician changed the prescription for Digoxin to 0.25 mg qd. The nurse would expect the physician to order which of the following laboratory tests?

A.  serum electrolytes and digoxin level
B.  WBC and hemoglobin and hematocrit
C.  Cardiac enzymes and an ABG
D.  Blood cultures and analysis

Correct Answer: A

The nurse plans care for a 15-year-old girl admitted with complaints of fever, vomiting and diarrhea. The nurse writes the following nursing diagnosis on the patient’s care plan: "fluid volume deficit". Which of the following changes in laboratory values would demonstrate an improvement in the patient’s condition?

In order to correctly answer this question, you must know:

• the normal levels of hematocrit (male and female) and specific gravity of urine
• how hematocrit and specific gravity levels are affected by a fluid volume deficit

Fluid volume deficit occurs when water and electrolytes are lost in the same proportion as they exist in the body. When a patient is dehydrated, both specific gravity of urine and hematocrit become elevated.

Correct Answer: letter B (Hct in females: 40-48%, specific gravity: 1.010 – 1.030)

Example:

A 45 year old man returns to the clinic two weeks after being started on allopurinol (Zyloprim) 200 mg PO daily. The nurse reviews information about this medication with the patient. Which statement by the patient indicates that the teaching was effective?

A.  "I should take my medication on an empty stomach."
B.  "I should take my medication with orange juice."
C.  "I should increase my intake of protein."
D. "I should drink at least eight glasses of water every day."

Correct Answer: letter D – Zyloprim can cause renal calculi….drink 3000 ml/day to reduce formation of kidney stones.

Example:

A 53 year old man is receiving PRBC. Several minutes after the infusion is started, he complains for itching and develops hives on his chest and abdomen. Which of the following actions should the nurse take first?

A. slow down the rate of the transfusion
B. call the physician for an order of antihistamine
C. mix IV fluid with the blood to dilute it
D. stop the transfusion

It sounds like the patient is having an allergic reaction tot he transfusion. What should you do first for this patient?

A. slowing down the rate of transfusion is not the right action
B. antihistamines are given for allergic reactions. This answer is a possibility but there is something you should do first!
C. This does not have anything to do with an allergic transfusion reaction.
D. This is the best action to take first before calling the physician.  (Answer)

Eliminate answer choices in which the nurse is telling the patient what to do without regard to the patient’s desires or feelings. Example:

• insisting that the patient follow unit rules
• insisting that the patient do what you command, immediately

Eliminate close-ended questions that can be answered with the words YES, NO or other monosyllabic answers. Close-ended questions discourage the patient from sharing thoughts and feelings. Example:

• "Are you feeling guilty about what happened?"
• "How many children do you have?"

Eliminate responses that are "why" questions: ones that seek reasons or justification. "Why" questions imply disapproval of the patient who may become defensive. Any response that puts the patient on the defensive is nontherapeutic and therefore incorrect. Example:

• "What makes you think that?"
• "Why do you feel this way?"

Avoid being a junior psychiatrist. Eliminate responses that include the word "explore". It is not the nurse’s role to delve into reasons why the patient is feeling a particular way. The patient must be allowed to verbalize the fact that he or she is sad, angry, fearful or overwhelmed. Example of "let’s explore" responses:

• "let’s talk about why you didn’t take your medication."
• "tell my why you really injured yourself."

Eliminate choices that offer false reassurance. These responses would discourage communication between the nurse and the patient by not allowing the patient to explore his or her own ideas and feelings. False reassurance discounts that what the patient is feeling.

Example:

• "It’s going to be OK."
• "Don’t worry. Your doctors will do everything necessary for your care."

Eliminate choices if the focus of the comment is on the nurse. Be careful, because these answers may sound very empathetic. The focus of your communication should always be on the patient. Example:

• "That happened to me once."
• "I know from experience this is hard for you."

THE RULES OF MANAGEMENT