NCLEX STRATEGY

   STRATEGY: When all options seems correct, look for the GLOBAL RESPONSE/ ENCOMPASSING

A client is post gastrectomy. Upon arrival in the unit, what should the nurse do?

1.    Take the pulse rate

2.    Take the respiratory rate

3.    Take the blood pressure

4.    Take the vital signs

Ans. 4

CHAIN OF COMMAND

   Problems associated with co-workers

   Problems on the rule of law

   If and when the doctor is not around,

*you have to coordinate / discuss with your immediate supervisor.

A nurse saw a co-worker injecting a dose of morphine sulfate that is intended for Mr. Blair, a post-appendectomy client. Which of the following is the best action that the nurse should do?

1.    Observe the nurse’s action further.

2.    Confront the nurse, tell him that if she continues to hoard morphine sulfate, she’ll be reported to the authorities.

3.    Approach the nurse supervisor and tell her about the incident.

4.    Keep silent and don’t get involved because you might become an accessory to the crime.

Ans. 3

   RULE OF COHORTING: Non-infectious with non-infectious; Infectious with the same infection

The nurse is caring for patients on the pediatric unit. An eight year old patient with second and third degree burns on the right thigh is being admitted. The nurse should assign the new patient to which one of the following roommates?

A.  A two year old with chicken pox

B.   A four year old with asthma

C.   A nine year old with acute diarrhea

D.  A ten year old with methicillin-resistant staph aureus (MRSA)

Answer: B

THE QUALIFIERS

Crucial word or phrases that changes the meaning of the entire question.

   The Negative Response stems:

   Unsafe…

   Least likely…

   Exception…

   Need for further…

   Lowest priority…

   Incorrect…

Choose negative/abnormal responses among the options.

A client returns to the clinic two weeks after discharge from the hospital. He is taking warfarin sodium (Coumadin) 2 mg. po daily. Which of the following statements, if made by the client to the nurse, indicates that further teaching is necessary?

A.  “I have been taking an antihistamine before bed.”

B.   “I take aspirin when I have a headache.”

C.   “I use sunscreen when I go outside.”

D.  “I take Mylanta when my stomach gets upset.”

Answer: B

   Universals/Absolutes:

   Absolute/ly, All, entire, only, any, every, each, always, completely, total, forever, wholly, force, must, never, unrestricted, whenever, insist

A patient complains that the elastic straps of the oxygen face mask feel tight. The nurse should:

1.    Explain that the mask must always stay firmly in place.

2.    Replace the face mask with a nasal cannula.

3.    Pad the straps with gauze.

4.    Adjust the elastic straps.

Answer: 4

Decide what’s Important!

   Do not focus on unnecessary information! PRIORITIZE!

Assess, Analyze/Diagnose, Plan, Implement, Evaluate:
A 12 year old sixth grade boy was riding his bike to school when he hit the curb. The boy tells the school nurse, “I think my leg is broken.” What is the first action the nurse should take?

1.    Immobilize the affected limb with a splint and ask the client not to move.

2.    Ask the client to explain what happened.

3.    Put the client in semi-fowler’s position.

4.    Check the appearance of the client’s leg

Answer: 4 (Assess / validate)

A 12 year old sixth grade boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert, conscious but in severe pain with a possible fracture of the right femur.  What is the first action the nurse should take?

1.    Immobilize the affected limb with a splint and ask the client not to move.

2.    Ask the client to explain what happened.

3.    Put the client in semi-fowler’s position.

4.    Check the appearance of the client’s leg

Answer: 1 (It’s time to do something, assessment is complete)


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