Walkthrough: Health Promotion and Maintenance Q6 – NCLEX-RN®

00:01 The nurse is assessing a client who reports shortness of breath.

00:05 The assessment findings include a pulse oximetry level of 90% on room air.

00:10 Blood pressure 190/100, crackles, auscultated in the bilateral lung bases, and a chest x-ray demonstrating bilateral pulmonary edema.

00:20 The nurse knows which actions are essential. Select all that apply.

00:26 Okay. That is a lot of words, that's why we still haven't shown you the answer choices because we have some work to do, some heavy lifting, before you go on to the answer choices in this select all that apply question.

00:39 So let's start at the top, first sentence, the nurse, that's me, is assessing a client who reports, ooh, pay close attention to that - a client who reports; whatever comes next is critically important.

00:56 Patients are our most important priority and if they're telling you something, in person or in the stem of a question, know that that really matters.

01:05 So I'm assessing a client and they report they are short of breath.

01:11 Now, that's an assessment coming from the patient, not normal.

01:15 Remember, for every assessment we ask ourselves, is that normal or abnormal? If a client is telling me they're short of breath that is abnormal.

01:24 Something needs to happen. Now, as you remember, the story gets worse.

01:28 But let's go on to the next sentence.

01:31 The assessment findings include, okay, now, I'm going to get a list of them.

01:36 A pulse oximetry level of 90% on room air.

01:40 Anytime you see a number, high, low, or normal, 90% on room air is low.

01:48 A blood pressure of 190/100, high, low, or normal? Ooh, that's high, right? 190, we're looking at normal being just roughly 120/80; so this is definitely elevated high blood pressure, both systolically and diastolically.

02:10 Remember, 190 is systolic, 100 is the diastolic number.

02:14 Now next piece, they have crackles auscultated in the bilateral lung bases.

02:21 That means that I have listened to both sides of the lungs, in the bases, I heard crackles, and that's a sign of pulmonary edema, right? So, is that normal? No. So let me see, I've got an abnormal pulse ox.

02:36 I've got an abnormally high blood pressure.

02:38 I've got crackles in both lungs, bilateral, in the bases, because that's where it's going to start.

02:45 Crackles usually start in the bottom and you'll hear them on their way up.

02:47 And, a chest x-ray demonstrating bilateral pulmonary edema.

02:54 Okay. That lines up. That's abnormal, but it lines up with what I'm listening to.

02:59 So long story short, I have a client who's reporting shortness of breath.

03:04 I have a pulse ox that's low that goes along with shortness of breath.

03:08 Blood pressure that's high, not surprising if they're feeling like they can't breathe.

03:13 Crackles in bilateral in the bases, and a chest x-ray that supports pulmonary edema. That all lines up.

03:20 Now here's the final sentence - the nurse knows which actions are essential.

03:28 Select all that apply. Okay, you got this. You know that you're going to have more than one option.

03:34 I don't want to bring them on, yet, because I want you to focus on the select all that apply strategy.

03:39 Now that you've walked through that question, pause the video, put this question into your own words.

03:47 No-no, seriously. Pause the video. This is the best mental gymnastics you can do to help your brain get stronger and faster at answering questions correctly.

04:02 Okay, now, obviously, I can't hear how you broke the question down, but I will do something like this: Okay, I have a client that's reporting shortness of breath.

04:11 They're showing me all the signs of, they're not oxygenating well, right, and they have crackles.

04:17 So I'm looking for something that's essential.

04:20 So I'm looking for something that will keep this client who has pulmonary edema safe.

04:27 Okay. Now let me show you the answer choices and I want to you to work through them.

04:31 You'll see there's five answer choices there.

04:33 I want you to work through them one at a time and say number 1, is administer a stat diuretic, an essential action for a patient who is short of breath in pulmonary edema, okay? Go through each one of those five answer choices.

04:50 Ask yourself the question. Remember, we summarize what was in the stem of the question.

04:54 Ask yourself that question five separate times.

04:58 Now, you're using a piece of scratch paper, it has only the numbers, number 1, number 2, number 3, number 4, and number 5 written on it.

05:06 You'll cross those off or circle them to keep them in as you work through the answer choices, but make sure you force your brain to say why.

05:15 Okay, so don't just say, hmm, I think that one, that one, that one.

05:18 Say, yes, I'm going to keep it in and here's why. I'm going to take it out and here's why. Ready? Alright. Take all the time you need to use this strategy and practice this question.

05:30 Don't worry if you get it wrong, we got some solutions for that.

05:34 But what I want you to do is to pause the video, do the work of walking through this question.

05:39 Then we'll come back, talk about the rationales, and you can learn even more about what strategies you're actually using in taking your test.

05:54 Welcome back. Let's take a look at these five particular answers.

05:59 Now, remember, you may not like these answers; you may wish there was another answer here, it doesn't matter.

06:06 When you're taking a test question you have to treat this like playing a game of cards.

06:10 These are the cards that you've been dealt and you have to choose from these options which ones are appropriate.

06:17 So let's start with number 1.

06:18 Is it essential to administer a stat diuretic if someone has pulmonary edema? Yeah, it is. Remember, pulmonary edema is a sign of fluid volume overload, so a diuretic will help pull some of that volume off.

06:35 Now some of you may be saying, wait a minute, I don't have an order for that? Actually, you do. In NCLEX questions, if you have something that says, administer a stat diuretic, you can be assured that you have an order for it.

06:48 Now, that may not apply in your nursing school exams, we can't address that with your individual school, but we can tell you, on the NCLEX exam, you can assume that you have an order for that.

07:01 Now, number 2. Is it appropriate for someone or essential for someone in pulmonary edema, if we administer supplemental oxygen? Yes, it's appropriate, so hopefully, you kept that one in.

07:14 Remember, their pulse ox is low, it's 90, we know they're in pulmonary edema, that means their lungs are not going to be able to function as they normally would, so they're going to need some supplemental oxygen.

07:27 Number 3, encourage increased oral fluid intake, is that appropriate for a client who has pulmonary edema? No. No, no, no. We don't want them to drink more, right? We're going to count it, we're probably going to limit their fluids, so encouraging them to increase oral fluid intake is a no, that is not essential for taking care of a client in pulmonary edema.

07:54 In fact, it's worse that not being essential, it could be harmful.

07:57 Number 4, is it essential for a client with pulmonary edema to elevate the head of the bed? Okay, so what would that do? If we raise the head of the bed, oh, yes.

08:09 That is the position that we put a patient in who's having a hard time breathing.

08:14 We don't want them lying flat, we want to elevate the head of the bed, right, they've got the weight of their chest off of them.

08:21 If they're lying flat, all of this is just pushing down under their lungs, so if you elevate the head of the bed, it will be easier for them to breathe.

08:31 And really, if your client is oriented, they will fight to get themselves in this position anyway, because we just instinctively know, this is safer.

08:38 Now, number 5. Is it essential for a client with pulmonary edema for us to administer an anti-hypertensive medication.

08:49 Okay, well, maybe not so much for the pulmonary edema, but what information do we have in the stem of the question that address blood pressure? Oh, yeah. Its high, 190/100.

09:04 So would it be appropriate to give an anti-hypertensive medication? Absolutely.

09:09 So the correct answers are number 1, number 2, number 4, and number 5.

09:16 Now, what can you take from this question to use on other questions? Is there any nursing fact or clinical judgment that you saw on this question that you want to make sure you add to your notebook so you can review it? Hey, what if there is. Please make sure you pause the video and take the time to write that down before you go on to another question.