Trend: Prioritization of Care – NCLEX-RN®

by Rhonda Lawes, PhD, RN

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    00:00 Hi. I'm Professor Lawes and in this portion of our video series we're going to look at the NCLEX questions called TRENDS.

    00:09 Now, this one is a special one because it's prioritization of care. So let's get started. First, here's our format.

    00:16 We're going to kind of give you a feel of what the environment would look like because I always want to encourage you to picture what's going on in your mind.

    00:23 It will focus your brain and help you raise your scores. So, 4 clients, not surprising.

    00:30 When it's a prioritization question, there is going to be 4 clients.

    00:34 So 4 clients presented to the emergency department at about the same time on Tuesday.

    00:38 The triage nurse obtains the medical histories and all 4 are admitted.

    00:44 Okay, not surprising, but we know where we are, emergency room, all 4 have been admitted.

    00:50 And now we're going to take a look at their histories.

    00:54 Client one, now remember this has nothing to do with priority, these are just randomly assigned.

    00:58 We'll have to figure out which one is the most unstable, who needs the most care first.

    01:05 All of these patients will be seen, all of these patients deserve to be seen, but your job as someone taking the NCLEX is to identify who's the most unstable requiring the most immediate care.

    01:17 So you see the time up there, it says Tuesday 08:00 to 08:30.

    01:21 Client 1, a 37-year-old client who sustained a motor vehicle accident yesterday. Okay. So, what do we know? Their age, we know what happened to them, they had a motor vehicle accident, and it happened yesterday.

    01:35 Now the client has no visible injuries on the body other than some abdominal bruising and pain, but reports feeling weak.

    01:44 Before you go on to client 2, think about what's the worst case scenario for somebody who has had a trauma like a motor vehicle accident.

    01:53 What's the worst possible case scenario? Is there any abnormal assessment in this question? Abdominal bruising is a little weird. Right? That's not normal. And what could that possibly indicate? The other thing is the patient reports feeling weak. Now that's all we have to go on.

    02:11 Accident yesterday. The patient has some abnormal feelings of feeling weak and they've got abdominal bruising and pain.

    02:21 Now, let's compare client 1 to client 2. Who's more unstable? Well, client 2 is an 82-year-old client. Oohhh, I was getting a little more worried about the elderly. They've got suspected food poisoning.

    02:33 Now they vomited 4 times today. We know that's not normal and likely to cause him to be dehydrated.

    02:41 Family reports that the client seems confused. Well, they're elderly and they're dehydrated.

    02:47 That would kind of check, that would kind of follow along that they would be confused.

    02:51 So, between 1 and 2, who do I think is more at risk? You know what? I'm not really sure. And sometimes that's going to happen to you.

    03:01 So let's say for now we're going to keep 1 and 2 in because we can't really make a straight up call yet.

    03:07 So I don't want that to throw you. You can come back to it and that's just a normal part of the process when you're taking a tough test like the NCLEX.

    03:16 So let's look at client number 3. Okay don't panic, don't think bad things about yourself or you're never going to pass the test.

    03:23 Just say "Uhh I'm not really sure right now. I'm going to go on to the next client and then I'll come back.

    03:29 6-month-old infant with increased drooling and rash on the lip and chin area.

    03:34 The mother states that the infant has been more irritable than usual.

    03:38 Or whether you have your own children or you've been around children, 6 months old children are usually cutting teeth. Right? And when they cut their teeth, they drool everywhere and they can get kind of irritated and that would be normal.

    03:53 So, client 3 is definitely not more unstable than client 2 or client 1 at this point. So I'm just kind of getting a lay on the land.

    04:02 Client 4, okay this is a 60-year-old client who had a cholecystectomy 6 days ago and reports severe pain at the surgical site.

    04:14 Alright, 60 years old, it's kind of around the border there, had a cholecystectomy (that's removal of the gall bladder) 6 days ago.

    04:22 Is it normal that they would be reporting severe pain at the surgical site? No.

    04:28 So see, this first time through I don't have near enough information to make a call.

    04:34 The only one I kind of have a suspicion about is like "Hhmmm, client 3 is probably just normal, typical, teething kid and mom brought them in." But let's keep moving through the question to make sure we haven't missed something.

    04:47 Okay, client 1. Whoah, update, 10 o'clock.

    04:50 Remember we were at 8:00 to 08:30, now we're at 10 am and that's what you'll see is a flow of information in the question.

    04:57 Client 1 has developed abdominal distension and dizziness. Remember what happened to this client.

    05:04 They had an MVA, they could've experienced some trauma, we had some weird bruising. Right? Some abdominal bruising. Now their abdomen is distended and they feel not just weak, but dizzy.

    05:17 Client 2, ohh the client has vomited 2 more times and is really not oriented to place now.

    05:23 So, that dehydration is probably growing worse by this point. Client 3, oh they feel very warm to touch.

    05:31 So, fever could mean infection but with the other signs, uhhmm I'm thinking that could be just cutting teeth.

    05:40 Number 4, oohhh, okay that's kind of gross. The surgical site exhibits a yellowish purulent discharge.

    05:48 Well, that's not a good sign and we are 6 days after surgery so that could be an infection.

    05:54 When I was a student and I tried to answer questions like this, I kind of start to feel my head start to spin because it's a lot of information but tell yourself just pause, take a breath.

    06:05 If you feel like I'm overwhelmed, I can't keep all this information separate, then just go back in the question when I show you the NCLEX format.

    06:13 You see how you can easily go back in the question and just follow client 1 all the way through to this point, and then client 2 all the way through to this point, client 3 and client 4.

    06:24 That will help reorient yourself and help kind of calm your nerves and diminish that confusion.

    06:30 So, this was our format. Now, we're going to show you what this is going to look like when you put everything side by side by side.

    06:41 So, look at client 1. You know my philosophy.

    06:44 You can either go directly down on client 1 which I would recommend then down 2, then 3, then 4.

    06:50 Look at each piece of information. Is it normal or abnormal? Heart rate for an adult of 107? That's fast.

    06:59 Blood pressure of 82/40? That's low. So we have a heart rate over 100, heart rate below 100. Respirations are fast.

    07:08 Temperature, fairly normal. A little on the low side. Pulse ox is 94%. That is right on the bottom of normal. So, they feel weird, they're dizzy.

    07:19 They have a bruise on their abdomen. Their heart rate is fast. Their blood pressure is low.

    07:23 Their respiratory rate is fast. Their temperature is not really that alarming.

    07:28 Their pulse ox is still normal but not fantastic for somebody that age.

    07:34 This is how you keep walking through and take the other information that you've read and piece it altogether.

    07:40 Now client 2. Remember, was this an old person? Was this a young person? Who was this person? Well, they have a heart rate of 110 a minute. Is that normal? Well, this is for an elderly client. Right? but we've got a heart rate of 110, it's a little high.

    07:58 Blood pressure is a little low, but not as low as 1. Right? The blood pressure is not as low as 1.

    08:04 Respirations are 20 a minute which is not as fast as 1. And temperature is a little elevated, maybe considered a fever because it's higher than 98.6.

    08:15 And their pulse ox is normal. So you're starting to keep comparison because remember all of the game is is who of these 4 people is the most unstable.

    08:26 Now, client 3. Okay, that's a little kiddo. So heart rate of 160. We're not as concerned if that had been one of the adult clients.

    08:34 Blood pressure 88/63. Remember to review your pediatric vital signs. Respiratory rate 58. Okay, that's pretty fast. Isn't it? But make sure you know your normals for the pediatric children's vital signs.

    08:51 Temp 37.9. Now, that's a little warm, but we know that that kid felt warm to us. And their pulse ox is 98%.

    08:59 So, not having any respiratory issues, but he's definitely breathing pretty fast.

    09:04 Client 4, heart rate 97 a minute. Uhhmm, still normal but it's kind of high.

    09:10 Blood pressure 148/92. That's high. Respiration of 22. Uhhmm, kind of on the upper end.

    09:19 I'm not super concerned about it, but it is up more than I'd be comfortable with.

    09:23 And 38 Celsius for a temperature or 104, just a little bit high. But pulse ox is looking pretty solid.

    09:33 So based on what I know, you just start to be formulating some opinions of what you think and then do the work of comparing each of these clients.

    09:42 Now, let's show you what it looks like on the screen.

    09:45 We wanted to break that all down for you so when you see this I don't want you to get overwhelmed, there's no reason to be overwhelmed by these questions.

    09:52 Take your time, be strategic, work through them left to right, first to end, and you're going to do fine.

    09:59 Look on the left side, information about the clients. You'll see that you have the 3 tabs there.

    10:04 You'll be able to go back and forth through those tabs as many times as you want, but I always recommend go through them thoroughly to make sure you see each piece of information about them.

    10:15 You see at the top, it reminds us that the client presented to the ER on a Tuesday? We know on the right hand side, we have 4 clients. Right? This is where we're going to do the work of the question and figure out who is the highest priority of these patients? Good news, we're not having to put them in order for 2nd, 3rd, or 4th who should be seen, just identifying who is the highest priority.

    10:40 Now, you see on tab 2 we've got the nurses notes and you've already seen these.

    10:44 Those says as things progressed from initially was 8 am to 8:30, now we've moved on to 10 am in the morning and here's how things have changed.

    10:53 That's why this is called a trend question. You're seeing a trend of vital signs and symptoms over a period of time.

    11:01 Right side? Still stays the same; client 1, 2, 3 and 4. 3rd tab, let's take a look at it. Vital signs.

    11:09 Now, you and I have already walked through all these, right, in detail but now I want to be sure that you're crystal clear on what is going to look like on the NCLEX exam.

    11:19 Now, our job is to compare each one of these clients, see who is more unstable than the others. Right? So, I always recommend doing this one at a time. So, client 1. I'm just going to start with 1 because that's what he was randomly assigned and let's take a look at it.

    11:39 Now I know that this gentleman had a motor vehicle accident yesterday. I know that any time you have a trauma, you're at risk for bleeding.

    11:47 Now, I'm going to say "Is there any signs in what I've seen in these trends that he is bleeding?" Well, he did have that weird bruising and that's a sign of abdominal hemorrhage.

    11:58 He feels weak, he feels dizzy, his blood pressure is low, his heart rate is high. Those are signs of hypovolemia.

    12:07 If he is bleeding into his abdomen, he will be experiencing hypovolemia.

    12:12 A blood pressure that low for a grown adult is really a sign that catches my attention. So for now, this dude is pretty serious.

    12:20 I'm worried about him bleeding into his abdomen and when the blood is in the abdomen instead of in the intravascular vessels, we're going to have trouble.

    12:30 Could leave him to shock. So for right now, I'm going to watch this guy super closely.

    12:36 But let's compare him to number 2. I do worry about elderly patients when they become dehydrated.

    12:42 I know that they're going to be confused and so these things are lining up. But how do I know they're dehydrated? Well, besides throwing up multiple times like 4 times before they came in, 2 since they've been here, I know that their heart rate is really high and their blood pressure is low.

    13:00 See, our first guy we think he might have those signs because he's hemorrhaging.

    13:05 We think client number 2 is having these signs of low volume because they've thrown up so much and they've lost so much fluid through vomiting.

    13:14 But if I had to pick between 1 and 2, alright I'm going to leave them both in because I know this can happen too so I'm going to leave them both in for now.

    13:22 If I'm looking at 3 and I saw the trend, yeah, I really think this kid is teething.

    13:27 And that's what the rush is and that is not going to trump our trauma victim in client 1 or dehydrated elderly person in 2.

    13:35 So number 3, I'm going to be able to just cross you off.

    13:39 Now, when I'm taking a test like this, I use the write on wipe off board and I write 1, 2, 3, 4.

    13:45 I wrote key notes about the patients and then I'll cross through them as I eliminate them as long as I say why.

    13:51 I'm eliminating client number 3 because they're just irritable, little cranky likely from cutting teeth because that's normal.

    14:00 All their other vital signs are normal, you know they're a little warm. So client 3 is not more unstable than client 1 or 2.

    14:10 Client 4, I really feel sorry for them because they're having this severe pain, they had surgery 6 days ago, they do have a fever.

    14:19 I'm always worried after surgery that someone could develop an infection and they sure looks like what client number 4 is doing.

    14:26 Fever, severe pain, and now they got the purulent drainage from the site. That's very probable infection for them.

    14:35 However, they are still more stable than client 1 and client 2.

    14:41 So I'm going to eliminate client number 4, I think that they are sign of infection, they will get treatment, we'll take care of them, but they're not the most unstable client at this point.

    14:51 So, we're left choosing between client number 1 and client number 2.

    14:56 Now, I think client number 2 is dehydrated and that's why their vital signs are low and we need to replace those fluids.

    15:01 But client number 1 is clearly the most unstable when I compare the two.

    15:07 Client number 1 is showing us multiple signs that he is hemorrhaging inside his abdomen.

    15:13 This could be a patient who is much more unstable and likely to arrest or code or at the very least go into hypovolemic shock.

    15:22 So number 1 is our most unstable client. Now, they just happen to be number 1.

    15:28 They won't do that or you on any of the other NCLEX test, but on this one it happened to be client number 1.

    15:35 Go back and look at your charting just a little bit more if you're uncertain in any way and say "I know it's number 1", list all the reasons.

    15:44 Bruising, bleeding, hemorrhaging, vital signs are abnormal, blood pressure is low, heart rate is high.

    15:50 He says he feels really dizzy and...there you go. I'm confident that number 1 is the one, check the box, and submit your answer. And that's it.

    16:00 You worked all the way through a trend question.

    16:04 Remember, as long as you are systematic, methodical, read all of the nurses notes, get those straight in your mind before you start eliminating patients, you're going to do just fine on these questions.

    16:16 So good luck and join us for more practice questions in our NCLEX review course.

    About the Lecture

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

    Included Quiz Questions

    1. Administer PRN benztropine intramuscularly.
    2. Insert an oral airway and start the client on oxygen at 6L/min.
    3. Offer the client PRN oral lorazepam.
    4. Place the client in Trendelenburg and take a complete set of vitals.
    1. A client, scheduled for surgical repair of their left hip at 1300 today, received PRN hydromorphone at 2330, 0300, and 0600 and presented with a respiratory rate of 8 breathes per minute and an oxygen saturation of 92% on room air at 0700.
    2. A client, set to be discharged at 1100 today, received PRN dimenhydrinate 0400 for nausea and reported drowsiness at 0700 and presented with a heart rate of 65 and a blood pressure of 100/62.
    3. A client, one-day post-tonsillectomy, reported difficulty sleeping related to anxiety and a sore throat at 0100 and 0400 and presented with a heart rate of 120 and a respiratory rate of 18 at 0630.
    4. A client, scheduled for diagnostic imaging at 0945 today to rule out a cervical fracture, received gabapentin at 2000 and reported worsening feelings of “pins and needles” to their hands and feet at 0530.
    1. A client reported feeling better today than yesterday and complained of mild dizziness, with a blood pressure of 98/60 and a heart rate of 80 at 0800 and at 0830 is not rousable to pain.
    2. A client complained of 8/10 abdominal pain, with a blood pressure of 145/90 and a heart rate of 110 at 0800, and complained of 9/10 abdominal pain and nausea at 0830.
    3. A client had three instances of emesis this morning, complained of aching joints, a heart rate of 80 at 0800, and is found to have a temperature of 102.2°F (39°C) and a heart rate of 110 at 0830.
    4. A client who fell during the night shift, complained of 6/10 back pain radiating to their legs at 0800 and reported 8/10 back pain radiating to their upper back and neck at 0830.

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

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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