STRATEGIES A. Reword the Question What is the question really asking? 1. Read the question carefully? 1.

Look for hints in stem of the question: most, best, first, initial, further teaching necessary, client understands teaching 1. Reword the question in your own words 1. If you cant do #3 - look at the answers for clues REMEMBER Further teaching necessary = looking for incorrect information/statement Client understands teaching = looking for correct information/statement B. Eliminating Wrong Answer 1. Cover all the answers except choice #1 1. Read choice #1 and repeat the reworded question. Ask yourself, Does this answer the reworded question? If it doesnt, eliminate it. If youre not sure, leave it for consideration. 1. Repeat the above process for the remaining choices 1. Note which answers remain 1. Reread the question to make sure youve properly/correctly reworded it 1. Choose the choice that best answers the question C. Dont Predict Answers 1. Reword the question 1. Select the BEST answer from the choices given D. Recognize Expected Outcomes Expected Outcomes = behaviors and changes that you think are going to occur as a result of nursing care Expected outcomes allow the nurse to evaluate if goal has been met Being able to recognize what is normal E. Read Answer Choices to Obtain Clues If you find yourself clueless after reading a question 1. Resist the impulse to reread the question (read it only once). Identify the topic of the question 1. Read answer choices to help figure out the topic of the question 1. After reading the answers - reword the question using the clues from the answer choices 1. Use strategies previously discussed to answer questions OR A more simplified version 1. Read the stem of the question 1. Identify the topic of the question 1. Read the answer choices

1.

Identify the nursing concept contained in the answers

CRITICAL THINKING PATHWAYS A. MASLOW Remember Maslows Hierarchy of Needs Self-Actualization, Self-Esteem, Love & Belonging Safety & Security Physical: threats (illness, accidents, environmental threats) Psychosocial: Knowledge/Education Pain Physiological Needs* - have to be taken care of FIRST Oxygen Nutrition Fluid Temperature Elimination Shelter Rest Sex Breathing Steps for Maslow Question 1. Maslow questions will have answer choices that include both physical and psychosocial needs of the client - identify that the question is a Maslow question 1. Eliminate all the psychosocial answers (education, pain, etc) 1. With the remaining answers, ask yourself, Does this answer make sense with regard to the situation or disease described in the question? If it does not, eliminate it. 1. Apply the ABCs (airway, breathing, circulation). If the ABCs dont apply, ask yourself, What is the highest priority? An Important Note Dont use ABCs without thinking the question through first Use ABCs to establish priorities, but they have to make sense Make sure the answer is appropriate to the question B. ASSESSMENT & IMPLEMENTATION (NURSING PROCESS) Assessment Establishing a data profile about the client Collecting data and comparing it to normal values Subjective & objective data Talking to client, observing client or significant others, taking a history, physical examination, evaluation of lab results, collaboration with other health care professionals FIRST STEP of the Nursing Process - priority over other steps of the nursing process

Dont implement before you assess Implementation Care you provide for the client Assist in ADLs, counsel and educate patient/family, giving care, supervising or evaluating the health care team Interventions Independent Interventions: within the nurses scope of practice (no supervision required) Dependent Interventions: require written orders from the doctor *Assume you have an order for all dependent interventions in the answer choices Steps for Assessment/Implementation Questions 1. Recognize that the question is an assessment/implementation question: for assessment/implementation questions, all the answers will be either assessments or implementations (a lot of times the question will end with What is the first action the nurse should take? Other clues: best, initial response) 1. Read the stem of the question to decide whether assessment or implementation is required in the situation. Has assessment already been done by the nurse? If not -- eliminate implementation answers (always assess first) 1. Select the best assessment or implementation C. SAFETY Safety Meeting basic needs such as oxygen, fluids, food Decreasing hazards or injuries such as accidents, obstacles Preventing transmission of pathogens through immunizations and sanitation Steps for Safety Questions 1. Recognize that the question is a safety question. With safety questions, all the answers will be implementations/interventions 1. Try to answer the question based on your own knowledge first 1. If you cantAsk yourself, What will cause the client the least amount of time? D. REAL WORLD *Dont answer questions based on your real world experience *Always choose the textbook answer Dont use real world experience to answer questions Assume you have all the time, staff, equipment that you need. Also, all care is given by the book (no shortcuts are used) 1. Take care of the patient first. The patient is your only concern 1. Remember, the NCLEX tests the nurses judgment
1. 1.

More Tips When in doubt - choose the textbook answer First take care of the client, then the equipment Know lab values Know medication administration Notifying the physician, contacting social worker, and referring to the chaplain are almost always WRONG They want to know what you, the RN, would do in the situation Make sure there isnt an answer that contains an assessment or action you should do before calling the physician E. THERAPEUTIC COMMUNICATION 1. Eliminate the following A. Dont worry answers = false reassurance B. Explore answers - youre not a junior psychiatrist Example: Lets talk about why you didnt take your medications C. Why questions - they put patients on the defensive D. Authoritarian answers Tell patients what to do without regard to clients feelings/desires E. Close-ended questions (yes or no) F. Focus on the nurse answers (I know how you feel because I had a similar experience 2. Use process of elimination Select the answer that includes 1 or both A. Gives correct information B. Empathetic/reflects clients feeling 3. Avoid passing off responsibility to someone else (avoid passing the buck) F. POSITIONING QUESTIONS Steps for Answering Position Questions 1. Are you trying to promote or prevent something by using this position? 1. What are you trying to promote or prevent? 1. Think about anatomy, physiology, and pathophysiology 1. Choose the position that best accomplishes what youre trying to prevent or promote G. MANAGEMENT OF CARE Rules of Management 1. Dont delegate assessment, evaluation, patient education, or nursing judgment 1. Remember, this is NOT the real world 1. Delegate activities for stable clients with predictable outcomes (DONT delegate unstable clients with unpredictable outcomes) 1. Delegate activities involved in standard, unchanging procedures

(bathing, feeding, dressing, transferring patient). DONT delegate complicated activities 1. Remember priorities: Maslow, ABCs, stable vs. unstable *NOTE: See one client and perform one activity

ANIONS Bicarbonate (HCO3-) Chloride (Cl-) Phosphate (PO4 3-) CATIONS Potassium (K+) Magnesium (Mg 2+) Sodium (Na+) Calcium (Ca2+) Calcium (ionized)

NORMAL VALUES 22-25 mEq/L or mmol/L 96-106 mEq/L or mmol/L 2.8-4.5 mg/dl or 0.9-1.45 mmol/L NORMAL VALUES 3.5-5.0 mEq/L or mmol/L 1.5-2.5 mEq/L (0.75-1.25 mmol/L) 135-145 mEq/L or mmol/L 9-11 mg/dl (2.25-2.75 mmol/L) 4.5-5.0 mEq/L 2.5-5.5 mg/dl (1.12-1.38 mmol/L) 2.25-2.75 mEq/L

Good Therapeutic Communication RESPONSE Using Silence

GOAL/PURPOSE Allows the client time to think and reflect Conveys acceptance Allows the client to take the lead in conversation Encourages the client to talk Indicates your interest in the client Allows the time for the client to choose the subject Encourages recall and details of particular experience Encourages description of feelings Seeks explanation Pinpoints specifics Paraphrases what client says Reflects what client says, especially the feelings that were conveyed

Using general leads or broad opening

Clarification

Reflecting

Positions POSITIONS Supine (flat) Dorsal Recumbent Side Lateral Sims (side with leg bent) Fowlers (head elevated) THERAPEUTIC FUNCTION Avoids hip flexion, which can compress arterial flow Supine with knees flexed More comfortable Allows drainage of oral secretions Allows drainage of oral secretions Decreases abdominal tension Increases venous return Allows maximal lung expansion High Fowlers: 60 - 90 degrees Fowlers: 45 - 60 degrees Semi-Fowlers: 30 - 45 degrees Low-Fowlers: 15 - 30 degrees Increases blood return to the heart Relieves pressure on lumbrosacral area Used to insert CVP line Treatment of umbilical cord compression Increases venous return Used for shock Increases venous return Increases blood volume to extremity Increases vaginal opening for examination Promotes extension of hip joint Not well tolerated by persons with respiratory or cardiovascular difficulties Provides maximal visualization of rectal area

Feet and legs elevated Trendelenburgs (feet elevated and head lowered) Modified Trendelenburgs (feet elevated 20 degrees, knees straight, trunk flat, and head slightly elevated) Elevation of extremity Lithotomy (flat on back, thighs flexed, legs abducted) Prone

Knee-Chest

Parameter pH PaCO2 HCO3(Bicarbonate) PaO2 Oxygen Saturation Base Excess

Arterial 7.35 - 7.45 35 - 35 mmHg 22 - 26 mEq/L (mmol/L) 80 - 100 mmHg 96% - 100% + or - 2.0 mEq/L

Venous 7.35 - 7.45 40 - 45 mmHg 22 - 26 mEq/L 40 - 50 mmHg 60% - 85% + or - 2.0 mEq/L

INTERPRETATION of ABGs Respiratory ALKALOSIS: pH and PaCO2 ACIDOSIS: pH and PaCO2 Metabolic ALKALOSIS: pH and HCO3 ACIDOSIS: pH and HCO3 R-O-M-E Respiratory - Opposite Metabolic - Equal RESPIRATORY OPPOSITE pH and PaCO2 = ACIDOSIS pH and PaCO2 = ALKALOSIS METABOLIC EQUAL pH and HCO3 = ALKALOSIS pH and HCO3 = ACIDOSIS