Walkthrough: Physiological Adaptation Q5 – NCLEX-RN®

00:01 The nurse is caring for a client who has an increased respiratory rate, is using their accessory muscles to breathe, and has a PaO2 of 56 millimeters of mercury.

00:11 The client has been on a venturi mask but is showing little improvement.

00:15 What method of support for this client's breathing would the nurse anticipate next? Okay. This is a great clinical nursing kind of question, right? What is your nursing judgement here? Well, let's break it down.

00:28 So I'm taking care of somebody who has showing me signs that things are not going well.

00:33 Their respiratory rate is increased. They're using accessory muscles to breathe.

00:39 You remember, those are the things that you don't normally use.

00:41 This indicates distress. They're not getting adequate oxygenation.

00:45 Now, a PaO2 of 56 is low. Normal's going to be about 80 to 100. So 56 is very low.

00:54 All three of those things, a higher respiratory rate, using accessory muscles, a really low PaO2 just supports this patient is in desperate need of something different. Right? Anytime you see abnormal assessment tin the stem of the question, you need to do something.

01:13 My top answer is not going to be document these findings.

01:17 No. They want you to keep this patient safe.

01:21 So they're telling us they've been on a venturi mask but they're clearly showing little improvement.

01:26 What method of support for this client's breathing would the nurse anticipate next? So in my own words, I have a patient that has abnormal respiratory assessment.

01:38 They're in distress. They're on a venture mask. What should I do next? Well, the cues that I look for in making my clinical nursing judgement here are just those things we talked about.

01:50 Increased respiratory rate, PaO2 of 56 and accessory muscles.

01:56 Those are abnormal assessments, but they're also cues.

01:59 Now that you've recognized them as cues, you analyze them, put it together and we decided our hypothesis is, "Wow, this patient is in respiratory distress.

02:10 And they need more than what they can get on a venturi mask." Okay. That's our topic. So what do we do for a patient who is in respiratory distress, right? They're inadequately oxygenated on a venturi mask. What's the next step? Here's where you get to use your clinical judgement. Let's look at the answer choices.

02:32 Please make sure that you number your scratch paper one, two, three, and four. Right? Excellent. Now, pause the video. You eliminate three of those answers and say why.

02:43 Remember, eliminate answers. Don't gravitate to answers.

02:47 Then come back and we'll talk through the question together.

02:59 Welcome back. Now, let's look at answer choice number one.

03:03 So an invasive method of oxygen delivery such as bi-level positive airway pressure.

03:08 Okay. You know what? I think in this type of question, I'm going to read through all the answer choices.

03:13 I usually suggest that. So give me a minute, I'll read them through in my head.

03:17 Okay. So I'm sure since you spent more time going through this question, you're very clear these are all about respiratory support.

03:31 But the problem that's kind of confusing for me is like the first three answers.

03:36 All I have BiPAP, BiPAP, BiPAP in them. So they're really close.

03:41 So, uh-huh, when I was in nursing school, my friend, my bestie told me that if three answers are the same and one answer is different, that must be the right answer. Wrong. That strategy will not work on an NCLEX exam.

03:59 So I'm telling you, there's a better way to get to the correct answer.

04:03 So I'm gonna slow my roll, slow my brain down, and let's look at these very carefully because I know they are so similar, there's got to be some minor differences that those people that write the NCLEX exam are trying to see if I recognize when I'm using my nursing clinical judgement.

04:24 So number one, an invasive method. Hey, that's a descriptor word, always important.

04:29 An invasive method of oxygen delivery, well, that would be, we may need to go to an invasive method such as bi-level positive airway pressure, BiPAP.

04:41 Wait a minute. Invasive method, BiPAP is not invasive. That's that mask that they wear.

04:49 So number one is a no go. What about number two? The need for a method of lower pressure delivery during inhalation and a higher pressure during exhalation which BiPAP can provide.

05:05 Well, I know that BiPAP is two different pressures. I'll come back to that one.

05:10 What about three? BiPAP because it reduces the need for intubation and mechanical ventilation.

05:17 Yeah. That's true, because I know that BiPAP, after BiPAP, the patient has to go on a ventilator usually if they decide to progress.

05:25 So far two and three. And I want you to get used to the fact, it's okay if you can't decide in or out right away. Move on to the next one.

05:35 When you find yourself stuck on answer choice and you're just going over and over and over and you can't sort it out, don't allow yourself to do that.

05:43 Move on to another answer choice, try to eliminate something, and then come back.

05:47 The students that I've worked with that have failed the NCLEX multiple times before, we got the opportunity to meet together and give them some strategies.

05:56 This is what happens to them. They get in a question.

05:59 They're unsure about an answer choice and they start really speaking negatively to themselves.

06:05 Don't do that. When you start feeling that, just say, "Look, I expected this.

06:10 I knew this was what was going to happen.

06:12 There's going to be some answer choices that are harder to eliminate than others, so this is not a surprise. It doesn't mean I'm going - not going to be successful.

06:21 It just means I'm going to move on because I'm not doing any good here right now." So far, we've left an answer choice two and three.

06:29 One was out because BiPAP is not invasive and we know descriptor words are really crafty ways that they try to trick us with those distractors.

06:39 But, nay, nay, that one did not catch us. Number four, continuous positive airway pressure, CPAP.

06:47 So when I go from a venturi mask to a CPAP because it delivers constant level of pressure to reduce the effort of breathing.

06:56 See, when I pick a CPAP, the other two are about BiPAP.

07:01 No, CPAP and BiPAP is more complex oxygen delivery. It's got those different pressures.

07:09 CPAP is just like strap on a hairdryer on to your face. Right? That's what a lot of people use for sleep apnea to keep those airways open.

07:17 But it does feel like they have put a hair dryer right on their face.

07:22 It's just whoo, constant continuous positive airway pressure.

07:26 So let's get rid of number four. Now, we're back to number two and three.

07:31 Not a problem because we didn't stress out. We just said, "I'm not sure." We eliminated one and four. Now, we're back to take a second look at it.

07:39 So I'm going to start with number three just because - BiPAP because it reduces the need for intubation and mechanical ventilation.

07:46 I know that's true, but is it the best answer? Well, we're going to look at two and see.

07:53 The need for the method of lower pressure delivery during inhalation and higher pressure during exhalation which BiPAP can provide.

08:02 Okay. Here's my strategy. That's a lot of words.

08:05 Well, when my brain in stressed trying to take a test, here's what I would do.

08:09 Lower pressure delivery during inhalation.

08:12 So I would have less air being forced in while I'm trying to breathe in, and I would have higher pressure when I'm trying to breathe out.

08:22 No. That is not good. But you see what I had to do? I had to take some extra steps to focus my brain.

08:29 I had to think through, what does that really mean in number two? Because when I did it that way, lower pressure when I'm trying to breathe and higher pressure when I'm trying to breathe out, that's not helpful and it's not BiPAP.

08:42 So the only possible correct answer here is number three. Was it obvious? No way. I guarantee you, a lot of people that take this question get really frustrated and they think there's all right answers and really, there's not on this question.

08:58 There's just enough difference in the distractors that if you don't really concentrate and remember what BiPAP is and what its purpose is, you have a really high chance of missing this question. So don't let them catch you.

09:12 Take your time, slow down, look at those distractor words, and make sure you eliminate and not gravitate answers. Look at number three.

09:21 Is it still correct? Does it meet what we're looking for? Absolutely. That is the purpose of BiPAP. Because we put a patient on that and hopefully, we can avoid intubating them which absolutely is an invasive procedure.

09:35 All right. That's it. Now, you're ready for the next question.