When caring for a client after surgery on the lower leg the nurse would assess the
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You will recognize priority questions on the NCLEX-RN® exam because they will ask you what is the “best,” “most important,” “first,” or “initial response” by the nurse. Show
As you read this question you are probably thinking, “All of these look right!” or “How can I decide what I will do first?” The panic sets in as you try to decide what the best answer is when they all seem “correct.” As a registered professional nurse, you will be caring for clients who have multiple problems and needs. You must be able to establish priorities by deciding which needs take precedence over the other needs. You probably recognized the baby’s jerky movements as an indication of hypoglycemia. Don’t forget that an important part of the assessment process is validating what you observe. You must complete an assessment before you analyze, plan, and implement nursing care. The correct answer is (3). The critical thinking required for priority questions is for you to recognize patterns in the answer choices. By recognizing these patterns, you will know which path you need to choose to correctly answer the question. There are three strategies to help you establish priorities on the NCLEX-RN® exam: • Maslow strategy We will outline each strategy, describe how and when it should be used, and show you how to apply these strategies to exam-style questions. By using these strategies, you will be able to eliminate the second-best answer and correctly identify the highest priority.
Expert Test TipJo Ann Scipio, NCLEX Instructor “Consider and visualize each question as a clinical situation.” NCLEX Question Strategy One: MaslowMaslow’s hierarchy of needs (Figure 1) is crucial to establishing priorities on the NCLEX-RN® exam. Maslow identifies five levels of human needs: physiological, safety or security, love and belonging, esteem, and self-actualization.  Because physiological needs are necessary for survival, they have the highest priority and must be met first. Physiological needs include oxygen, fluid, nutrition, temperature, elimination, shelter, rest, and sex. If you don’t have oxygen to breathe or food to eat, you really don’t care if you have stable psychosocial relationships! Safety and security needs can be both physical and psychosocial. Physical safety includes decreasing what is threatening to the client. The threat may be an illness (myocardial infarction), accidents (a parent transporting a newborn in a car without using a car seat), or environmental threats (the client with COPD who insists on walking outside in 10° F [−12° C] temperatures). To attain psychological safety, the client must have the knowledge and understanding about what to expect from others in his environment. For example, it is important to teach the client and his family what to expect after a cerebrovascular accident (CVA). It is also important that you allow a woman preparing for a mastectomy to verbalize her concerns about changes that might occur in her relationship with her partner. To achieve love and belonging, the client needs to feel loved by family and accepted by others. When a client feels self-confident and useful, he will achieve the need of self-esteem as described by Maslow. The highest level of Maslow’s hierarchy of needs is self-actualization. To achieve this level, the client must experience fulfillment and recognize his or her potential. In order for self-actualization to occur, all of the lower-level needs must be met. Because of the stresses of life, lower-level needs are not always met, and many people never achieve this high level of functioning. The Maslow Four-Step ProcessThe first strategy to use in establishing priorities is a four-step process, beginning with Maslow’s hierarchy. To use the Maslow strategy, you must first recognize the pattern in the answer choices.
Use the Maslow Four-Step Process to answer this practice question. NCLEX Question Strategy Two: Nursing Process (Assessment versus Implementation)A second strategy that will assist you in establishing priorities involves the assessment and implementation steps of the nursing process. As a nursing student, you have been drilled so that you can recite the steps of the nursing process in your sleep—assessment, analysis, planning, implementation, and evaluation. In nursing school, you did have some test questions about the nursing process, but you probably did not use the nursing process to assist you in selecting a correct answer on an exam. On the NCLEX-RN® exam, you will be given a clinical situation and asked to establish priorities. The possible answer choices will include both the correct assessment and implementation for this clinical situation. How do you choose the correct answer when both the correct assessment and implementation are given? Think about these two steps of the nursing process. Assessment is the process of establishing a data profile about the client and his or her health problems. The nurse obtains subjective and objective data in a number of ways: talking to clients, observing clients and/or significant others, taking a health history, performing a physical examination, evaluating lab results, and collaborating with other members of the health care team. Once you collect the data, you compare it to the client’s baseline or normal values. On the NCLEX-RN® exam, the client’s baseline may not be given, but
as a nursing student you have acquired a body of knowledge. On this exam, you are expected to compare the client information you are given to the “normal” values learned from your nursing textbooks. For example, when performing cardiopulmonary resuscitation (CPR), if you don’t access the airway before performing mouth-to-mouth resuscitation, your actions may be harmful! Implementation is the care you provide to your clients. Implementation includes: assisting in the performance of activities of daily living (ADLs), counseling and educating the client and the client’s family, giving care to clients, and supervising and evaluating the work of other members of the health team. Nursing interventions may be independent, dependent, or interdependent. Independent interventions are within the scope of nursing practice and do not require supervision by others. Instructing the client to turn, cough, and breathe deeply after surgery is an example of an independent nursing intervention. Dependent interventions are based on the written orders of a physician. On the NCLEX-RN® exam, you should assume that you have an order for all dependent interventions that are included in the answer choices. This may be a different way of thinking from the way you were taught in nursing school. Many students select an answer on a nursing school test (that is later counted wrong) because the intervention requires a physician’s order. Everyone walks away from the test review muttering, “Trick question.” It is important for you to remember that there are no trick questions on the NCLEXRN® exam. You should base your answer on an understanding that you have a physician’s order for any nursing intervention described. Interdependent interventions are shared with other members of the health team. For instance, nutrition education may be shared with the dietitian. Chest physiotherapy may be shared with a respiratory therapist. The following strategy, utilizing the assessment and implementation phases of the nursing process, will assist you in selecting correct answers to questions that ask you to identify priorities.
Use the Nursing Process to answer this practice question. NCLEX Question Strategy Three: SafetyNurses have the primary responsibility of ensuring the safety of clients. This includes clients in health care facilities, in the home, at work, and in the community. Safety includes: meeting basic needs (oxygen, food, fluids, etc.), reducing hazards that cause injury to clients (accidents, obstacles in the home), and decreasing the transmission of pathogens (immunizations, sanitation). Remember that the NCLEX-RN® exam is a test of minimum competency to determine that you are able to practice safe and effective nursing care. Always think safety when selecting correct answers on the exam. When answering questions about procedures, this strategy will help you to establish priorities.
Apply the saftey strategy above to the following question. What would be the nurse's focus when caring for a client after abdominal surgery?During the postoperative period, reestablishing the patient's physiologic balance, pain management and prevention of complications should be the focus of the nursing care.
Which nursing intervention is appropriate for a patient who is at risk of skin breakdown?Use moisture barrier ointments (protective skin barriers) or incontinence products in skin areas subject to increased moisture and risk of skin breakdown.
Which of the following terms is used to refer protrusion of abdominal organs through surgical incision?A hernia occurs when an internal organ or other body part protrudes through the wall of muscle or tissue that normally contains it. Most hernias occur within the abdominal cavity, between the chest and the hips.
Which client is at greatest risk for slow wound healing?Patients with diabetes, immobilization, and poor circulation are at greatest risk for chronic, non-healing wounds. Other causes include pressure ulcers or traumatic injury.
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