As with many exams, answering NCLEX-RN questions correctly isn’t always as easy as it seems. Sometimes figuring out exactly what the question is asking can be difficult, which is why the first step is to find the keywords. Keeping an eye out for certain phrases that alert you to the keywords of a question can help you identify how to answer it successfully. These phrases usually relate to one of the five steps of the nursing process.
Assessment and priority
The first stage of the nursing process is always assessment. Common questions related to the assessment phase of the nursing process may require you to set priorities when performing patient assessments. Questions may ask which assessment is most important, has the highest priority, or is the priority for a particular client. These kinds of questions are likely to start with or include the phrases Which priority assessment or Who would the RN see first. The latter is a priority assessment of which client is in the most life-threatening condition.
© Nekrasov Andrey / Shutterstock.comPractice question
A nurse is caring for a client who has just had elective nasal surgery for a deviated septum. Immediately after the surgery, the nurse performs which priority assessment?(1) Measuring intake and output
(2) Determining the client’s pain level
(3) Checking for impaired swallowing
(4) Assessing respiratory status
The correct answer is Choice (4). The biggest keywords here are nasal surgery, highest priority, and immediately after surgery. When answering questions about priority assessments, remember that more than one answer option may be correct. In this question, all the options are assessments that should be performed immediately post-op nasal surgery. But the question asks which assessment assumes the highest priority, and for priorities you need to remember that life-threatening issues are the priority in every case. As a result of the nasal packing and edema of the airway, the nurse should carefully assess for signs of respiratory compromise. Nasal packing may also dislodge, resulting in obstruction of the airway.Diagnosis
Questions relating to the nursing diagnosis step of the nursing process usually present information about a patient situation and ask you to identify an appropriate nursing diagnosis or the priority diagnosis. In order to make any kind of diagnosis, you need to- Organize the data that you’re given
- Analyze the data
- Determine what you feel is the highest priority in terms of nursing care
Practice question
A client with a newly created colostomy has verbalized to the nurse that he thinks the opening in his abdomen is disgusting and he doesn’t want to look at it. Which nursing diagnosis would be most appropriate?(1) Knowledge deficit related to the care of a stoma
(2) Disturbed personal identity related to change in appearance
(3) Disturbed body image related to colon surgery
(4) Hopelessness related to irreversible changes in body functioning
The correct answer is Choice (3). Organize the data (new colostomy, client’s feelings about the stoma, refusal to look at it) in the keywords. Then analyze that information and determine what the priority concern is. In this case, the primary concern is that the patient has verbalized negative feelings about his stoma in terms of how it looks. Therefore, the priority nursing diagnosis is disturbed body image. The client’s feelings aren’t related to a knowledge deficit but rather to a permanent change in physical appearance. Hopelessness may be an issue, but the question contains no data to support this diagnosis. Disturbed personal identity relates to a client’s inability to distinguish between self and nonself.Planning and assigning care
Many exam questions address your ability to plan patient care that meets all the patient’s needs. Common questions pertaining to the planning step of the nursing process may address one of the following topics:- Planning for delegation of tasks
- Developing patient teaching plans
- Formulating patient outcomes/goals
Practice question
A nurse is assigning the care of a patient with a modified radical mastectomy to a nursing assistant. Which intervention can’t be delegated to the nursing assistant?(1) Collecting a clean catch urine specimen and sending it to the lab
(2) Emptying the patient’s Foley catheter and recording output
(3) Assisting the patient out of bed and into the chair on the first day post-op
(4) Assessing the operative site for drainage
The correct answer is Choice (4). When answering questions about delegating care, first look at who the care is being delegated to and consider what that person is qualified to do. The Nurse Practice Act and individual hospital policy define and limit the scope of nursing practice, but generally, unlicensed personnel aren’t permitted to perform patient assessments, administer medications, or perform medical treatments. Unlicensed personnel, such as nursing assistants, can perform activities such as ambulation, positioning of patients, bathing, hygiene measures, and collection of some urine and stool specimens. In this question, assessment of the operative site for drainage is a nursing responsibility and therefore can’t be delegated. The other activities can safely be performed by the nursing assistant, but the nurse is accountable for the assistant’s activities.The teaching plan
Nurses are teachers; making sure that patients understand their care is an important part of nursing. Questions pertaining to patient teaching may be worded something like Which instructions would the nurse include in the teaching plan?Practice question
The nurse is preparing for the discharge of a toddler admitted with nephrotic syndrome. Which instructions would the nurse include in the teaching plan for the parents?(1) “Call the physician if the child has an increase in urine output.”
(2) “Keep the child away from others with infections.”
(3) “Administer antipyretic medication as ordered.”
(4) “Assess urine specific gravity every day.”
The correct answer is Choice (2). Find who the client is, the condition, and what the question is wanting, in this case teaching plans. When answering questions about teaching plans, think about what you know about the patient’s condition and incorporate this information into the teaching plan. The child recovering from nephrotic syndrome should be protected from infection. The physician should be notified if the child has a decrease, not an increase, in urine output. Specific gravity assessments aren’t appropriate for a child being discharged to home, and antipyretic medication isn’t indicated.Outcomes and goals
As a nurse, you need to know why you perform specific nursing interventions. In other words, what are you expecting to happen when you do certain things? These expectations are called expected outcomes and goals. NCLEX-RN questions on planning patient outcomes and formulating goals may contain the phrase Which would be an expected outcome. An easy way to understand this concept is to think about the expected outcome of taking, say, cold medication. If you take one of those fizzy tablets, for example, you probably expect not to have a cold anymore, or be able to breath freely.Practice question
The nurse is planning care for a patient admitted with bacterial pneumonia. Which would be an appropriate expected outcome for the patient?(1) The patient performs activities of daily living without dyspnea.
(2) The patient expectorates a moderate amount of yellow sputum.
(3) The patient’s white blood count (WBC) is 14,000 cells/mm3.
(4) The patient’s urine output is greater than 30 ml/hr.
The correct answer is Choice (1). When formulating outcomes, first consider the patient and his or her condition. Figure out what the nursing or medical diagnosis is, and then ask yourself, “How will I know the patient is getting better?” An appropriate expected outcome- Is observable and measurable
- Specifically addresses the patient’s nursing or medical diagnosis
Best response
The implementation step of the nursing process refers to how the nurse carries out nursing actions. Common questions pertaining to the implementation step of the nursing process may ask you to- Identify the nurse’s best or most therapeutic response in a certain situation
- Identify the nurse’s immediate or priority action
- Identify the appropriate nursing interventions for a specific disease or condition
Practice question
A client who has been hospitalized frequently for major depression tells the nurse, “I don’t understand why I get so depressed.” Which would be the nurse’s best response?(1) “I’m sure you’ll improve with the right medication.”
(2) “Would you like to talk about the reasons you’re depressed?”
(3) “This must be very upsetting to you.”
(4) “Your depression is most likely caused by a chemical brain imbalance.”
The correct answer is Choice (4). In answering implementation questions, carefully consider all the responses to determine which one contains accurate information and is therapeutic for the client. In this situation, the best response acknowledges that depression has a biochemical basis. Stating that the client will improve with medication or is upset doesn’t address the client’s immediate concern about the cause of his depression. Talking about the reasons for the depression isn’t the best response because it does nothing for the client other than increase depression.This situation is where you want the client to talk about his feelings or emotions. When you see this type of question, use therapeutic communication techniques such as
- Reflecting: Directing the client’s question back to client
- Restating: Repeating what the client has said
- Using silence: Allowing time for formulating thoughts
- Focusing: Keeping the conversation focused toward the task
- Asking closed ended questions: These questions elicit only a yes or no response.
- Giving advice: “You really shouldn’t . . .”
- Minimizing the client’s feelings: “Cheer up.”
- Making a value judgment: “I don’t think that’s good.”
Priority action
Nursing care actions need to be performed in a certain order. Some actions are always more essential than others, and you need to know what to do first.Exam questions relating to priority action are likely to be worded “What should the nurse’s priority action be?” or use the phrases initial action or immediate action.
Practice question
A client with chronic immune thrombocytopenic purpura undergoes a splenectomy. Upon receiving the patient in the PACU (postanesthesia care unit), the nurse immediately assesses the client’s airway and vital signs. What should the nurse’s next priority action be?(1) Checking the patient’s Foley catheter for urinary output
(2) Administering pain medication as ordered
(3) Checking the patient’s dressing for excessive bleeding and drainage
(4) Administering platelets as ordered
The correct answer is Choice (3). To determine priority action, first consider the patient and his or her conditions. Next, determine what the essential nursing interventions are for the condition and determine which condition is the most life threatening for the client. In this case, chronic immune thrombocytopenic purpura (ITP) is an immune-mediated disorder of platelet destruction. A client undergoing a splenectomy with a history of ITP is at high risk for hemorrhage, and therefore the priority assessment is to check the dressing for signs of bleeding. Although the nurse should check the urine output and pain level, these conditions aren’t immediately life threatening.Interventions
Nursing requires you to anticipate what may happen with your patient given his disease process. Thinking ahead in this manner allows you to watch for signs of problems and intervene as quickly as possible. To determine whether you know the appropriate nursing interventions for a particular disease or condition, exam questions on this topic usually ask “The nurse can anticipate which intervention?”Practice question
A client has developed hepatic encephalopathy as a result of liver disease. Which intervention can the nurse anticipate incorporating into the plan of care?(1) Restricting fluid to 1,000 ml/day
(2) Inserting a nasogastric tube
(3) Administering intravenous salt poor albumin
(4) Implementing a low-protein diet
The correct answer is Choice (4). From the way the question is worded, you know that only one of the interventions listed is a priority in this situation. When hepatic encephalopathy develops as a result of liver disease, one of the treatment goals is to reduce the production of ammonia. One of the by-products of protein breakdown is ammonia, so protein should be limited in the patient’s diet. Fluid restriction and salt poor albumin are used to treat ascites (a complication of liver failure). A nasogastric tube may be inserted as the disease progresses, but it isn’t the best answer here.Further teaching
The last step of the nursing process is evaluation. Common phrases in these types of questions pertain to determining whether patient goals have been achieved and interventions have been successful. For example, questions may include the phrases Further teaching is necessary when, Interventions have been effective when, or Intervene when.Practice question
The nurse is caring for a client receiving subcutaneous injections of enoxaparin sodium (Lovenox) for a pulmonary embolism. Which statement made by the patient indicates that further teaching about the medication is needed?(1) “I’ll watch for signs of bleeding and notify my physician immediately if I notice anything.”
(2) “I’ll avoid medication that contains aspirin.”
(3) “My doctor will be checking my platelet count regularly.”
(4) “I’ll need to have my coagulation levels checked daily.”
The correct answer is Choice (4). Needs more teaching means you’re looking for the incorrect statement. When you see this type of question, rephrasing the question in your mind is often helpful to figure out what it’s really asking. In this case, you can rephrase the question to be “Which is an incorrect statement made by the patient?” Choice (4) is incorrect and is therefore the right choice. Enoxaparin sodium (Lovenox) is a low molecular weight heparin used to prevent deep vein thrombosis; it’s also given to patients with pulmonary edema. As for the other options, patients with normal coagulation who are receiving enoxaparin don’t require regular monitoring of coagulation levels. The patient needs to watch for signs of bleeding and to avoid aspirin. Platelet levels are checked periodically because thrombocytopenia is a potential side effect of the drug.