Mark Klimek NCLEX Review: Prioritization, Delegation, Staff Management, Guessing Strategies
Mark Klimek NCLEX Review: Prioritization, Delegation, Staff Management, Guessing Strategies
- This is the most important Unit in the whole review
- There will be at least 15 questions on this section alone
- Most exam takers dead guess in the section
- Learn the material and do not guess
Prioritization
Prioritize - you are deciding which patient is sickest or healthiest… Make sure you know what you’re looking for
Question
For instance, if the question states that there was a disaster in town and you are making room for the wounded, who would you discharge?
- In that case, would you be looking for the highest or lowest priority patient?
- Answer: the lowest priority patient
Question
However, if the question states that you receive handoff end-of-shift reports on 4 patients. Which patient will you check first?
- Answer: the highest priority patient
Answers will usually have 4 parts
• (1) Age, (2) Gender, (3) Dx, and (4) a modifying phrase
For example: A 10-year-old male with hypospadias is throwing up bile-stained emesis
- Age: 10-year-old
- Gender: male
- Diagnosis (Dx): hypospadias
- Modifying phrase: throwing up bile-stained emesis
• 2 of which are irrelevant for answering the question
- Age and gender are not important in prioritization
• Age is important in pediatrics
• Of all 4 parts, the modifying phrase is more important
Remember
The modifying phrase is always the most important
Example
Two patients: one has angina pectoris and the other myocardial infarction. Who has the higher priority patient?
- Answer: The MI patient
- Go by the patient’s condition since there is no modifying phrase
Example
Now modifying phrases are added to each of the diagnosis, which patient becomes the higher priority?
a. Patient with unstable BP and Angina
b. Patient with stable vital sigh and MI
Answer: Patient with angina and unstable BP becomes the priority patient
4 Rules for Prioritization:
1. Acute beats Chronic
- Meaning that an Acutely ill patient has higher priority than Chronically ill patients
- For instance, among the following pts, a patient with COPD, CHF, or appendicitis, which one has the highest priority?
- Pt with appendicitis (acute condition). Both COPD and CHF are chronic conditions
2. Fresh Post-op (12 hours) beats medical or other surgical
- For instance, among the following pts, a pt 2-hour postcholecystectomy, a pt with COPD, and a patient with acute appendicitis, which pt has the highest priority?
- The 2hour postcholecystectomy is the highest priority pt(Fresh post-op, <12hr)
- Pt with “radical neck dissection” is added to the above scenario?
- The 2-hour postcholecystectomy is the highest priority pt
- Pt with “bilateral above the knee amputation” is added to the above scenario?
- The 2-hour postcholecystectomy is the highest priority pt
- Pt with “right frontal craniotomy” is added to the above scenario?
- The 2-hour postcholecystectomy is the highest priority pt
The point here is that surgery less than 12 hours takes precedence over medical and other surgical conditions
3. Unstable beats Stable
- This means that an Unstable patient has a higher priority over Stable patients
How to determine that a patient is stable or unstable?
Word description that makes a patient STABLE
- Stable
- Chronic illness
- Post-op greater than 12 hours
- Local or regional anesthesia
- Lab abnormalities in the A or B level
- Creatinine, BUN, Hemoglobin 8 to 11,
Bicarb, elevated Hematocrit, elevated
BNP, elevated Na level, RBCs off
- Ready for discharge, To be discharged,
Admitted longer than 24 hours
- Unchanged assessment
- Experiencing the typical expected S/Sx of the
disease with which they were diagnosed
Example
Which of the following patient is the highest priority?
a) A 16-year-old female with meningococcal meningitis who has had a temp
of 103.8 ºF since she was admitted 3 days ago
b) 67-year-old male with IBS (irritable bowel syndrome) who spiked a temp
of 103.4 ºF this afternoon
Answer: the 67-year-old patient has the highest priority
• 16-year-old: Dx: meningococcal (acute)—high
- Who has had (constant)—low
- Temp of 103.8 (expected)—low
- Admitted 3 days ago (>24 hours)—low
• 67-year-old: Dx: Irritable bowel syndrome (chronic)—low
- Temp spiked (changed)—high
- This afternoon (acute)—high
Four things that always make you unstable, even if they are expected
- Hemorrhage (but not bleeding)
- High fevers over 105 ºF - can lead to seizure
- Hypoglycemia - can lead to brain damage
- Pulseless or Breathless
- Example, V-fib or asystole
- Exception: At the scene of an unwitnessed accident pulseless and breathless pts are low priority because they are likely dead. Therefore, low priority
In a mass casualty incident, these 3 things result in a BLACK TAG
1. Pulseless
2. Breathless
3. Fixed and dilated pupils (even they are still breathing)
Therefore, “Tag them black and ship them last”
4. Tie Breaker Rule
If the above 3 rules result in a tie breaker, use the following as a guide
- The more vital the organ, the higher the priority
- Use this rule with the organ of the modifying phrase and not the diagnosis
1. Brain
2. Lung
3. Heart
4. Liver
5. Kidney
6. Pancreas
Example
a. You have a 23-year-old male with CHF (chronic—low) with K (6.6—high), and no EKG changes (constant—low)
- Organ: Heart (potassium)
b. Chronic Renal failure (chronic low) with a creatinine of 24.7 (expected—low), and pink, frothy sputum (unexpected—high)
- Organ: Lung (frothy)
c. Acute Hepatitis (acute—high) with jaundice (expected—low), increased ammonia (expected—low) who you cannot arouse (unexpected—high)
- Organ: Brain (He Wins!)
Example
Determine whether the following are stable or unstable
- Angina pectoris—stable
- Angina pectoris with crushing sternal pain—stable, (expected)
- Angina pectoris not relieved by rest—not stable
Delegation of Responsibility
Do not delegate the following responsibilities to an LPN.
An LPN is not allowed to assume the following responsibilities … The LPN:
1. Cannot start an IV
2. Cannot hang or mix IV meds
3. Cannot push IV Push meds
- LPN can only maintain an IV and document the flow
4. Cannot administer blood or deal with Central lines … Including flush, change dressings
5. Cannot make the care plan … They can however implement the care plan
6. Cannot perform or develop teaching … They can reinforce teaching
7. Cannot take care of unstable pts
8. Cannot perform the “first” of anything … The first of anything is either making the care plan or assessment
For instance, the LPN:
- Can perform tube feeding only after the nurse did the first tube feeding
- Can change post-op dressing only after the nurse change the first dressing
- Should they change the first post-op dressing the day of surgery? No
- Can feed stroke pt only after the nurse did the first feeding
- Can ambulate post-op pt only after the nurse had first done so
- Can take pt out of bed post-op only after the nurse had first done so
- Can take a set of V/S post-op only after the nurse had first done so
9. Is not allowed to assess: admission, d/c, transfer, or first assessment after a change.
Example
I think I heard new crackles on that guy in Room 52. Who should go assess this pt? ... The RN or the LPN?
- The RN must assess the pt since this is a new onset or change of a symptoms
Example
So who should the RN check? And who should the LPN check?
a. Angina with crushing substernal chest pain, 3 days ago, on nitro
b. Subtotal thyroidectomy done 2 days ago and now states “why are they watching elephants?”
- The RN should check the pt with subtotal thyroidectomy (onset of a new and worsening symptom, which may be thyroid storm)
- The LPN should check pt with angina with crushing chest pain (expected)
Do not delegate the following responsibilities to a UAP
1. Charting - UAP can chart what they did but they cannot chart about the pt. For
example,
- They can chart, “side rail is up, bed is lowered, etc.”
- They cannot chart, “patient less anxious, tolerated ambulating well”
2. Medication administration - They can’t administer medications unless med is:
- Topical medications, over the counter (OTC) medications, and barrier creams
- Cannot give Nitroglycerin or Neosporin ointments because nitroglycerin and Neosporin are not OTC
- Can they give hydrocortisone cream? No
- Can they give A&D ointment? Yes
3. Assessments - Except vitals or Accu-Chek for diabetes
4. Treatments - Except for enemas
The RN may delegate ADL (activity of daily living) tasks to a UAP … However, the UAP should never do any ADL task first.
What to and not to delegate to the family members and friends of patients:
- Never delegate to the family safety responsibilities. For example, if a family member or friend of patient tells the RN
- “Would you leave the restraints on my dad off and I’ll call you before I leave?”
The answer is: Do NOT delegate safety responsibility to family members or friends of patients
- RN cannot delegate safety to a non-hospital caregiver unless the person is trained (seater) on how to do the tasks. The RN must document in the pt’s record what exactly was taught
- Can the mother give insulin shot to her 3-year-old child? Yes, if you teach her and document teaching.
- What if a new mother asks the RN to “leave the railing of my baby’s crib down and I will put it back up after finish bathing my baby. You can go about what your business”
The RN’s answer should be something similar to that. “Don’t worry about me leaving, I will stay with you to make until you are done.”
The point is to make sure the rail is put back up before you leave the room
Staff Management
How do you intervene with inappropriate behavior from staff?
This is not prioritizing, this is not delegating … this is handling staff members who did stupid things
There are always 4 answers
1. Tell Supervisor
2. Confront them and take over the task the staff is implementing immediately
3. Talk to them later
4. Ignore it
Never ignore inappropriate behaviors … So, “ignore it” is the wrong answer
- Use the incident as an opportunity to teach and change behavior
Choosing among the remaining 3 options depends on the nature of the incident … Therefore, ask yourself one of the following?
- Is the staff doing something Illegal?
- If answer is YES … Then, Tell Supervisor
- If what the staff is doing is not illegal?
- Then ask yourself if anyone (patient, the co-worker, or other staff member) is in
immediate of physical or psychological harm?
- If answer is YES … Confront immediately and take over
- If no one is in harm’s way, ask yourself if this behavior is simply inappropriate
- If so, talk to that particular staff at a later time about the incident
Examples
1. You suspect the RN is diverting narcotics. Tell Supervisor
2. The Aide is giving perineal care to pt, not wearing gloves? Confront and take over the task.
3. The RN is going home with bulging pockets? Tell Supervisor
4. You notice surgeon contaminates her gloves? Confront
5. The RN always gives report, always says exasperation instead of exacerbation …
Talk to them later
If an illegal act can be harmful to the patient … first, takeover the task and then report the incident to supervisor
Questions
What if you find 2 patients involving in sexual intercourse? What is best thing to do?
- Shut the door and give then privacy
- As a staff, you do the same if you stumble upon a patient masturbating in his or her room
Organ Location
If a question is asking you to identify a named organ on a picture on the screen, it is a simple point-and-click on the organ on the screen … To do so, move the mouse over the area and click
- An “X” identifies the organ you want to select as your answer
- As long as you are in the general vicinity, you will identify the organ, given you are correct
Auscultation Over Heart Valves
When answering questions to identify heart valves, you must click exactly over a narrow area as to mimic stethoscope placement. The areas auscultated for murmurs (or sounds) are remembered by “A PET M”
- The Aortic valve is located in the 2nd intercostal space, right of the sternal border
- The Pulmonic valve is located in the 2nd intercostal space, left of the sternal border
- The Erb point is rarely asked on the exam
- It is located in the 3rd intercostal space, left of the sternal border
- Erb point is between the pulmonic and the tricuspid valve
- The Tricuspid valve is located in the 4th intercostal space, left of the sternal border
- The Mitral valve is located in the 5th intercostal space at the midclavicular line
- The apical pulse is in the same location as the mitral valve auscultation
Palpating for Pulses
Know where on the body these pulses are located
- For instance, anticipate questions about identifying the popliteal pulse on a picture on the human body
Guessing Strategies
Everybody taking this exam will guess at some point. Instead of guessing blindly, here are some strategies that can help you answer questions correctly
Use these approaches when all the answers do not make sense …
1. In psych nursing
• Pick, “I will examine my feelings”
- This is to prevent countertransference
- Countertransference: A patient reminds a nurse of her dad, who she a bad relation with, so she interacts in a hostile manner with the patient
• Or pick, “Establish a trust relationship”
2. Nutrition
• When all else fails, go with “baked”—not fried—but “backed chicken”
- If there is no chicken, pick fish—not shellfish (lobsters, crabs, or shrimp). Shellfish is high in cholesterol
• Never pick casseroles for children—they won’t eat it
- A casserole is any kind of stew or side dish that is cooked slowly in an oven
• Don’t mix meds in kids’ food
- Always ask pts for permission before you mix their food and medication together
• For toddlers, pick “finger food”
- Examples are: Hot dogs, tofu, French fries
- Your answer should focus on what can they eat on the run
• For preschoolers, “leave them alone”
- One meal a day is ok
- Growth curve around preschool year plateaus … Toddlers growth curve goes up
3. Pharmacology
• Memorize S/E
• Don’t memorize dosage, route
• If you know what a drug does but don’t know the S/E, how do you proceed? … Pick the “S/E in the same body system the drug is working”
- For instance, if you have a GI drug, and drowsiness, tachycardia, and diarrhea are part of the answer choices. What S/E will you pick? Pick “diarrhea”
- From the same above list … For cardiac drug, pick “tachycardia”
- For CNS drug, pick “drowsiness”
- If you have no idea what the drug is … and the drug is PO, pick a GI side-effect
• Never tell a child a “medication is candy”
- The child may give grandma’s valium to other children thinking the pill is candy
4. OB: check “fetal heart rate”
5. Med/Surge
• What is the first thing to assess? “Check for LOC (level of consciousness)”—not airway
- Think about a code or you find a pt on the floor … LOC is always checked first
- “Sir, Sir, Sir! Are you ok? Can you hear me?” If there is no response, A-B-C is then done next
• What is the first thing to do? “Establish an airway”
6. Pediatrics
• For growth and development, you can always narrow down your answer to three rules, which goes along “giving the child more time”
- Rule #1: When in doubt, “call it normal” … Example: Some six year olds can read. Some can and some can’t. Pick the answer that says, “Give the child more time” … There is no doubt that a 13-year-old who not potty-trained is normal
- Rule #2: When in doubt, pick the “older age” in the 2 that it could be … In what age can the child walk? Both 12 months and 14 months are right … Pick 14 months. In that case, you give the child more time
- Rule #3: When in doubt, pick the “easier task” … At 6 months, a baby can roll over or sit with support … Pick “roll over” as your answer because it is the easier task.
• In growth and development, there are always two correct answers. The mantra is to give the child more time … Chant in your head: “NORMAL, OLDER, EASIER”
7. General guessing skills
• “Rule out absolutes” … That is if you are guessing. However, it is commonly known to never push potassium
• Avoid answer choices that say the same thing … Neither one is correct. For instance, the following 2 answer choices are the same. Answer choice #1: Increased bowel sounds … Answer choice #2: borborygmi. Pick a different one
• If two answers are opposite, one is probably correct
• Umbrella strategy … Find more than one correct answer? Find the global answer. Ex: Use safety and good body mechanics if possible
8. Prioritization of patient needs
• Patient is need with the worst outcome has the highest priority—in other words, pick the Worst Consequences Game
- For example: Which is highest priority for suicidal patient? (a) Don’t give tranquilizer. (b) Don’t orient to unit? (c) Don’t put him on suicide precautions? And (d) Don’t introduce him to staff?
To answer this question, ask yourself is: “What would happen if I did not implement the task?” Answers: (a) Agitated, (b) Lost, (c) DEAD, (d) Doesn’t know anyone. The worse case scenario is (c). The pt would be DEAD. Answer choice (c) is the answer.
9. When you’re stuck between two answers … Go back and read question.
You probably missed something
10. The Sesame Street Rule
• When nothing else works, look at all the answer choices to see which one looks different from the others
- Looking at the picture below, one is not like the others … If that happens on the exam, the answer choice that looks different is likely the right answer
- The wrong answers look the same
11. Don’t be tempted to answer based on ignorance rather than knowledge
• If you don’t know drug, pull it out of the question and try to answer based on fundamental knowledge or common sense
- For example: The Piggyback question about Amikacin … You don’t know the medication Amikacin, but you do know that piggybacks need a pump. Don’t analyze those first 10 questions on the NCLEX. USE COMMON SENSE
12. The are 3 expectations you are not allowed to have:
• Expectation #1: Remember—the test will not be what you expect
- Go to the exam center and expect 265 or 285 questions
- Prepare yourself to go for the maximum
- If you freak OUT when you get to 86 (RN) or 96 (LPN) and on, it might impact your performance on the exam … Negativity will kill you
- This is a computer-adapted test—if you get to 200 you’re not failing … You’re still in the game!
• Expectation #2: Don’t expect to know everything. It ain’t happening
• Expectation #3: Don’t expect a perfect day
- Perfect parking spot
- Perfect Seat Partner
- You stuck it out through nursing school this far … You have perseverance and strength of character
- Get through one question at a time