Bowtie: Prioritization of Care – NCLEX-RN®

by Rhonda Lawes, PhD, RN

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    00:00 Hi, I'm Professor Lawes and in this video series, we're going to show you how to answer a bowtie question.

    00:08 That's one of the format's on the Next-Gen NCLEX.

    00:11 Now they call it a bowtie because you have two options on the left, one option in the middle, and two options on the right.

    00:18 So it kind of looks like a bowtie.

    00:21 This one isn't just any kind of bowtie, this is a prioritization of care.

    00:26 That means you're going to see for clients, and you're going to have to determine what we need to do first, who's most at risk? So walk with me through this question, and I'll teach you the key strategies on how you can be successful on these types of questions.

    00:43 Okay, so we're in the ER.

    00:44 The nurse receives the end of shift report regarding a for client assignment.

    00:49 Now, those of you that have worked in an ER, I know you know, like, what? An ER nurse would never have just four patients.

    00:57 That's okay.

    00:58 In NCLEX world, this is how it goes, you're gonna have four options.

    01:03 Now, in privatization of care, it's important that you remember, every client deserves to be seen, every client deserves care, and they will get care.

    01:12 But on this exam, the idea is do you recognize who has the highest priority? Who's most at risk? Who needs intervention first to maintain their safety? Okay, so it's going to feel frustrating.

    01:27 Prepare yourself, because you're thinking, "Oh, my goodness, all these people need care." They do and they'll get it.

    01:33 But the whole goal of this game is can you recognize who's the most at risk in the most danger? And who you need to intervene with first? Okay? So prepare yourself.

    01:46 When you feel your brain getting frustrated, say, "oh, that's normal." People feel like that. I'm proud of the questions all the time.

    01:54 How do I work through this? Let's start with client one.

    01:58 Now client one has a history of seizures, and is on a sub therapeutic on their medication.

    02:04 No, that is a mouthful.

    02:06 Levetiracetam is how you say that.

    02:08 But whoa, that is a lot to say that medication is used to treat their seizures.

    02:15 If their subtherapeutic that means it's not doing as much as we would like it to, to prevent seizure activity.

    02:22 Look at the second point.

    02:24 Client experienced a tonic-clonic seizure 30 minutes ago that lasted for approximately one minute, and received lorazepam to break the seizure activity.

    02:33 Currently, the client has a GCS of 13.

    02:37 Vitals are stable.

    02:39 Okay, that's a lot of information.

    02:41 Whether you have ADHD or not, when you see all that going by you in a test and you're stressed, it's really hard to pick up the pieces.

    02:49 So what I want you to do is go back.

    02:52 Let's look at them and take it one step at a time.

    02:54 So I can retrain my brain to think about this information and put it in my mind in an organized way.

    03:01 So they have a history of seizures, got it.

    03:04 Their subtherapeutic on their medication for the seizures, which means it's not doing the job like we would like it to.

    03:12 They have had a tonic-clonic seizure.

    03:15 Oh, they give me a timeframe.

    03:17 It was 30 minutes ago.

    03:19 It lasted about a minute.

    03:20 But remember, it was 30 minutes ago.

    03:23 So we had to give them Lorazepam.

    03:25 But that was during the seizure to break the seizure activity.

    03:29 Right now in the right now, client has a GCS of 13.

    03:33 We're okay with that.

    03:35 And vitals are stable.

    03:37 Okay, that's client one.

    03:39 So you have a feel for them.

    03:41 You kind of got it solid.

    03:42 Do a summary in your mind one more time of what's going on with this patient.

    03:46 Now we'll go on to client 2.

    03:51 Client 2 was admitted for an elevation in serum troponins.

    03:55 Now these have peaked and are now trending down.

    03:58 That's really important.

    04:00 Serum troponin tells us there's been some heart muscle damage.

    04:04 Now they were elevated, but they're trending down.

    04:07 That's a good sign.

    04:08 That's what we want them to do.

    04:10 They did a repeat ECG, and there's no new findings.

    04:15 So you've given them nitroglycerin paste 1 hour ago, but they're still having pain 7/10.

    04:22 Okay, this is the questioning, is this like a circulation issue? Now administered IV morphine for the pain 15 minutes ago.

    04:29 So we're watching this person, anybody having some heart issues, really gets our attention.

    04:35 So right now I'm already thinking, "I have a feel for what client one is doing." They seem pretty stable, even though we're going to watch them closely.

    04:44 If I look at client to do I think they're more critical.

    04:49 Do they have more things at risk? Well, yeah, I do because they have elevated serum proponents.

    04:55 They've peaked and now they're trending but still, that's a cardiac issue, which is going to be a bigger deal since the seizure is not actively happening, it's over.

    05:04 The ECG shows no new findings, we've given them nitrile pace, but they're still having pain.

    05:09 That's a bigger deal than 30 minutes after a seizure.

    05:13 And we gave IV morphine 15 minutes ago.

    05:16 Okay, so we've got to see, go back and check and see how that's going.

    05:21 But I'm kind of thinking between 1 and 2, 2 is the most severe.

    05:26 That's a key strategy.

    05:28 Make sure you're solid on what the first client is, you've done that summary in your mind, then you go to the second client and think, "Okay, let me get a good feel for this client." Now, I'm going to compare this client to that client.

    05:41 Trust me, it is much easier to use this strategy where you can pair them one at a time.

    05:48 So whichever one you've determined is pretty much the highest priority, then you compare the next patient to them.

    05:55 And then finally, the fourth patient.

    05:57 This helps your mind stay clear and focused, rather than trying to look at all four and figure it out at one time.

    06:03 So, so far, number two.

    06:05 There our winner for needing the most attention.

    06:09 There our highest priority when comparing 1 to 2.

    06:13 Now we're going to look at client 3.

    06:16 They're admitted for a hip replacement yesterday, and their pulse ox dropped to 88% in the evening.

    06:23 Respirations are 26/min, pulse at 112/min.

    06:28 Client was placed on 4 L of nasal cannula oxygen 15 minutes ago.

    06:33 All right, so they had a hip replacement yesterday, their pulse ox dropped to 88%.

    06:39 Anytime I see a number, that's an assessment, I asked myself, is that high, low or normal? Well, in this case, 88%, it's too low.

    06:48 It shouldn't be that way.

    06:49 They've had an orthopedic procedure, and their pulse ox is dropped.

    06:53 That gets my attention.

    06:55 I gotta think what is going on.

    06:58 Respirations are 26/min, too high.

    07:01 Pulse 112/min, too high.

    07:04 So this is telling me that they're having some respiratory issues.

    07:09 They shouldn't be breathing that quickly.

    07:11 Why are they breathing that quickly? And why is their heart rate 112? So put the client on four liters of nasal cannula 15 minutes ago.

    07:21 So if I'm comparing number 2 to this 1, number 2's proponents are coming down.

    07:27 Right, so that helps me think, "All right, they're kind of coming down.

    07:32 We haven't seen any new changes.

    07:34 This one is having respiratory problems.

    07:36 Now I know all of you know ABCs.

    07:39 It's something you want to be thinking about when you're prioritizing patient care.

    07:43 If someone has an airway issue, a breathing issue or circulation issue, those are usually three top priorities.

    07:51 So I'm going to say that number 3 is more danger, more in danger, then client number 2.

    07:58 So, so far, client three is my top priority.

    08:03 So I've only got one left.

    08:05 Let's see what we have.

    08:08 So Client 4.

    08:10 They're admitted for respiratory distress, and they have a history of cirrhosis of the liver.

    08:15 Okay, so there, they were admitted for respiratory distress.

    08:18 And they have a history of cirrhosis of the liver.

    08:21 You do a physical assessment.

    08:22 No surprise, they have ascites, right? And usually, that's what makes it difficult for someone with liver failure or cirrhosis, to breathe.

    08:31 Because they've got so much fluid in this abdomen, it just makes it difficult for them to bring air in and out.

    08:39 They did a paracentesis yesterday.

    08:42 So the client is currently verbally upset, demanding to go outside and smoke.

    08:49 Hey, we don't take this lightly in the hospital, we recognize that someone who has a habit of smoking, it's really tough for them to not be able to smoke.

    08:58 So you don't want to downplay this, you're gonna have to use some of your nursing skills.

    09:01 But if I compare client 4 to client 3, who do you feel is your highest priority? Okay, you decide, let's work through the rest of the question.

    09:13 But first, I want to show you what it's going to look like on the screen.

    09:17 Do you see that? If I sat down and looked at this question, I would be immediately overwhelmed.

    09:25 That's why I didn't show it to you in the beginning.

    09:28 I wanted you to see if you will read through each one of those clients, compare them to each other, looking for the one highest priority.

    09:37 Now it's going to be easier for us to answer this bowtie question.

    09:41 So on the left side of the screen, when you're taking your NCLEX exam, you'll see all the information about our patients.

    09:47 On the right side, you'll see the actual bowtie port of the question and the three columns that lists the options.

    09:55 You're going to click and drag the best options each to one of the answer choices.

    09:59 Okay, so let's work through that.

    10:02 First column is action to take, then we have potential condition.

    10:06 And then we have the parameters to monitor.

    10:09 Those are always the three columns that you see in a bowtie question.

    10:12 The only one that's a little bit different with this one is that the potential condition is either client 1, 2, 3, or 4.

    10:22 Now, if we've done our homework, right? And we walk through each one those clients slowly, clearly, we have an idea of who we think is our highest priority.

    10:31 Now we're working through the answer choices.

    10:33 So I'm going to blow that up bigger for you so you can see it, there you go.

    10:38 It's just easier to visualize this way, you know that it looks like the slide we just looked at previously.

    10:44 That's what it looked like on the NCLEX.

    10:46 But let's walk through these options now, so you can see them more clearly.

    10:50 Which client requires priority actions by the nurse based on the description of the condition.

    10:56 So this is where you click and drag, right? From the choices below.

    11:00 This will help you specify which condition the client that the nurse prioritizes is most likely experiencing.

    11:07 Two actions the nurse takes to address the assignment, and two parameters the nurse monitors to avoid complications and check the client's progress.

    11:15 Again, a lot of works.

    11:18 Let's go back through that.

    11:20 These will be the directions that you'll see if it's a bowtie prioritization question.

    11:24 It's telling you complete the diagram.

    11:27 How do you complete it? Drag from the choices below to specify which condition the client that the nurse prioritizes is most likely experiencing.

    11:38 Two actions the nurse takes to address the assignment and two parameters the nurse monitors to avoid complications and to check their progress.

    11:47 So those same three columns that you'll see in all bowtie questions.

    11:53 So let's start with actions to take, run the left hand side of the bowtie, two of these five options are going to be correct.

    12:01 So do you see the tricky part? If you look at these options, you'd be like, "Well, these are all important things to do, right? These are things that we should do for a patient.

    12:10 I want to do these things." Remember, everyone is going to get care.

    12:14 Everyone deserves care.

    12:16 Our job is to make sure that we have focused on who did we think was the most important? Think back, was a client 1? Well, that was the cardiac, right? Oh, no.

    12:28 Who was client one? Think about client 2, client 3, and client 4.

    12:37 If you can't remember them, this would be a key time when you're taking the questions to go back and look at that information and make sure you're clear on who they were.

    12:46 Do you still feel comfortable with your choice of who we think is the highest priority? Well, tentatively, we thought it was number 3, right? So let's look at the options.

    12:58 Starting left to right, the first option is use de-escalation, therapeutic communication.

    13:05 Okay, that's important.

    13:07 And if you've been in an ER and I just spent some time this past week, 24 hours in the ER, and they definitely had to use their de-escalation, therapeutic communication with some of those clients.

    13:19 But when you're looking at this, who I would most likely use this for is the client in number 4, that's become verbally agitated.

    13:26 Now, he's not the top priority.

    13:29 Because their condition is fairly stable that the paracentesis yesterday, right.

    13:35 So this one is not likely going to be one of the actions that I take, because it doesn't reflect something that I would do for the patient we've identified as a priority which is number 3.

    13:47 Okay, moving left to right.

    13:50 Set up bed padding.

    13:51 Okay, which of these four clients would we set up bed padding for? Client 1, the one who had the seizure.

    13:59 Now they had it 30 minutes ago.

    14:02 They're not having a seizure right now.

    14:03 So they're actually fairly stable.

    14:07 And padding the bed rails really shouldn't take priority over the patient number 3 who's having breathing difficulty.

    14:13 So that's also UAP, or an LPN could do that task.

    14:19 So that doesn't have to be done by the RN.

    14:21 On the NCLEX exam, remember, we're looking for what the RN should do unless it asks us otherwise.

    14:29 So in this case, setting up bed petting is not our top priority.

    14:34 Moving on, listen to lung sounds.

    14:38 Hey, we think number 3 is the one that's got a high priority and listening to lung sounds, would that be appropriate? Yes, because that means the nurse is going in and evaluating the client in person.

    14:52 They're putting hands on the client to evaluate them.

    14:55 That's always a good thing.

    14:57 In this case, is that the priority? Yes. Because you're listening to lung sounds as talking about respiratory distress that will give us key information that we need.

    15:07 Okay, so that's probably going to be one of our options.

    15:10 But let's finish out the last two.

    15:15 Plan on cardiac catheterization.

    15:17 Which client would that be? Oh, the guy with elevated troponin is right.

    15:22 But he hasn't had any new ECG findings.

    15:26 So they're not going to have to run this guy straight to cath lab.

    15:30 So what we're going to do here is yes, we're going to follow through on that, but it is not a higher priority than the patient who's having respiratory distress, that's number 3.

    15:39 Okay, so think we're gonna get rid of that one.

    15:41 So far, we've only kept in listen to lung sounds.

    15:45 Now let's look at the last option together.

    15:48 Obtain pulse oximetry.

    15:50 So Ooh, that is checking on right oxygenation, put it on the patient's finger, or other appendages, can let me know what the saturation is of their hemoglobin.

    16:01 Okay, that sounds like a good idea for us to monitor somebody who's having respiratory distress.

    16:07 So let's look back at those five.

    16:09 Do you see the two that we picked? Listen to the lungs obtain a pulse oximetry.

    16:15 Does that make sense for the patient in number 3? Yes.

    16:19 Do you still feel confident that's the patient that we feel is in the most distress and the highest priority? See, that's the key when you're doing these prioritization, bowtie questions.

    16:31 That's why spending time in the beginning, going through the patients and comparing them to each other one by one and determining who's the most unstable, or the highest priority, that's the magic.

    16:42 So, we've done the actions to take.

    16:46 Now let's take a look at potential condition that really means the priority client.

    16:51 Well, this part we already know, right? Like, why are we noting this now? It's okay.

    16:57 You walk through those we look at the actions to take, we saw which client those would most likely go with, determine what were the priority.

    17:05 Because remember, they don't tell us do this for client 1, this for client 2, this for client 4, they're looking for you to be able to sort that out in the actions to take part of the bowtie.

    17:14 Now, potential condition is the priority client.

    17:17 We're all pretty agreed on this one, it's client number 3.

    17:22 Now let's walk through why that is.

    17:24 Remember, client 1 is postictal.

    17:26 They're after a seizure.

    17:28 But this is a normal state for somebody having a seizure.

    17:32 It should resolve within an hour or so.

    17:34 And they're actually pretty stable.

    17:37 As long as we've got them, keeping an eye on them, which we are, they should be fine.

    17:41 That's why number one was not the highest priority.

    17:45 Number 2, yes, they had elevated troponins.

    17:48 Yes, their cardiac was involved.

    17:50 However, these are trending downward, and there's nothing else that tells us this patient is more unstable than client 3.

    17:59 Remember client 3, they're at a high priority because they're having difficulty breathing, the road to set had gone down before.

    18:06 So we want to keep an eye on them.

    18:08 Another thing you may not have thought of, they had an orthopedic procedure that puts them at risk for a pulmonary embolism.

    18:16 So any patient after an orthopedic procedure big one like a hip has trouble breathing.

    18:22 You want to be thinking could this be a pulmonary embolism? So using the ABCs, this is the one that is our highest priority.

    18:30 Now let's do number 4, just so you remember what that's like, oh, yeah, that's the gentleman who is upset.

    18:37 They're not really happy with what things are going.

    18:40 They're at risk, they call it elopement or maybe leaving against medical advice.

    18:44 However, that doesn't take top priority over client number 4, not in real life, and not on an NCLEX question.

    18:53 So we've got that in the middle, Client 3.

    18:57 There are condition or our priority client? So, got it? We're gonna listen to lung sounds, obtain a pulse ox.

    19:04 Because we determined, client 3 was the highest priority.

    19:09 Now we got to look at what are the parameters to monitor.

    19:12 Before you even look at the answer choices, here's what I want you to think.

    19:17 If I know it's client 3 and I know that they're having respiratory distress, whatever I'm going to follow would have to do with ongoing addressing that respiratory distress.

    19:28 Now I'm going to look at the answer choices.

    19:31 Oxygen saturation, level of agitation, pain assessment, abdominal girth measurement and respiratory assessment.

    19:39 Okay, I'm going to walk through these slowly because this is what I want you to do when you take the test.

    19:44 Oxygen saturation.

    19:46 That makes sense.

    19:47 Client number 3, breathing issue, I need to follow up and assess him and stay right on top of that.

    19:52 See if the oh two that we started has been effective.

    19:55 So yes, I'm thinking oxygen saturation for sure.

    19:59 Level of agitation.

    20:01 Now who does that apply to that client 4? Right, their medical condition is relatively stable, but they're really upset and they're getting agitated.

    20:11 That is something we're going to follow up on.

    20:14 But I'm not thinking that's a higher priority than oxygen saturation.

    20:19 Pain assessment.

    20:21 Now client 2 is having pain and its chest pain, which normally gets our attention.

    20:26 But we're not seeing other changes that make us really concerned, proponents are coming down.

    20:32 So we will see this patient but they're not a higher priority than client number 3.

    20:39 Now, anyone else? Really, we didn't deal with pain in 1, they're postictal.

    20:45 Two was our chest pain guy, and they are having pain.

    20:47 Three is the one with respiratory and four is the patient with cirrhosis, and previous ascites.

    20:53 So the only one pain assessment could be attached to is number 2.

    20:59 That's what you have to do when you're thinking through these like, which patient does this refer to? Do you see why it's so important to identify the highest priority patient first, then this becomes much easier? Otherwise, I could talk myself into circles thinking every answer is correct.

    21:17 Now, you may be more clear on that than I am.

    21:19 But I know this is how it is when your brain is stressed.

    21:21 This is why we recommend that you do it this way.

    21:24 Now we've got two other options.

    21:25 So far we've picked oxygen saturation.

    21:30 Abdominal girth measurement.

    21:32 Of all four of these patients, who would we do abdominal girth measurement with? Do you do that for a seizure? No.

    21:40 Do you do that for chest pain? No.

    21:43 Do you do that for respiratory like the patient in 3? No.

    21:46 Do you do that for 4? Yes, that's part of our assessment before and after a paracentesis kind of helps us measure how much we're able to relieve the patient from that fluid.

    21:56 But this is not going to be our top priority now, right? The paracentesis was yesterday, we probably or may not do this on today, but we may.

    22:07 Either way, it's not a higher priority than taking care of the respiratory distress.

    22:12 Oh, thank goodness, option five, that deals with respiratory assessment.

    22:17 So reassessing the respiratory assessment, brilliant idea! Beyond the pulse ox, you want to go in and put your hands on the patient.

    22:26 Figure out if they're improving.

    22:27 Is the nasal cannula enough? Do we need to increase it? What do we need to do? Do we need to titrate that oxygen? Those are all critically important things that you're going to do for a patient and respiratory distress.

    22:39 So up there, the last two choices.

    22:43 Parameters that are most important for you to monitor are the ones that help our priority client number 3, oxygen saturation and respiratory assessment.

    22:54 So that's it.

    22:55 You did it! You worked your way through another bowtie question.

    22:59 And again, not just any bowtie question, but a prioritization bowtie question.

    23:05 So what are key strategies? I want to review really quickly.

    23:10 Remember, it's so important when you have, who should I see first? That you work through each one of those four patients.

    23:18 Compare number 1 to number 2, who's the highest priority? Then compare them to number 3 and then compare to number 4.

    23:26 If you do that first, it's going to make the rest of the question flow much more smoothly.

    23:32 You're not going to get as confused as if you just tried to plow through the question.

    23:36 So what I want you to do is make sure that you identify the client that you feel is the highest priority.

    23:41 And then when you're on the left side of the bowtie, or the right side of the bowtie, pick the options that address that client that is the highest priority.

    23:51 Well done.

    23:52 Keep going and join us for another video series on how to answer Next-Gen NCLEX questions.

    About the Lecture

    The lecture Bowtie: Prioritization of Care – NCLEX-RN® by Rhonda Lawes, PhD, RN is from the course Next Gen NCLEX-RN® Question Walkthrough.

    Included Quiz Questions

    1. The client, one day post facial surgery, complaining of new-onset difficulty swallowing, with stridor and an oxygen saturation of 89% on room air
    2. The client, one-hour post orthopedic surgery, presenting as drowsy with a respiratory rate of 12 and a heart rate of 58.
    3. The client, 12 hours post bowel surgery, complaining of abdominal distension with a moderate amount of sanguineous drainage to the incision site.
    4. The client, six hours post abdominal surgery, complaining of 5/10 pain to their incision site with a heart rate of 100 and a blood pressure of 95/50.
    1. Ask the client if they are having difficulty breathing and assess vital signs.
    2. Call the healthcare provider and request orders for antibiotics.
    3. Administer the client’s prescribed anticoagulant and encourage the client to ambulate.
    4. Apply a cool compress to the affected area and elevate the client’s leg.
    1. The client scheduled for physiotherapy in 30 minutes and reporting 6/10 hip pain.
    2. The client requesting a bed bath before their family comes to visit.
    3. The client due to receive a scheduled intravenous immune globulin infusion.
    4. The client with a heart rate of 110 bpm, a blood pressure of 115/85 mm Hg, and is anxious about their impending discharge.
    1. Have the client sit down.
    2. Call the client’s healthcare provider.
    3. Listen to the client’s heart.
    4. Obtain an oxygen saturation reading.
    1. Actions to take
    2. Potential condition
    3. Parameters to monitor
    4. Assessment findings
    5. Required follow-up

    Author of lecture Bowtie: Prioritization of Care – NCLEX-RN®

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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