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
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