What Interventions Should the Nurse Implement to Determine the Patency of the Nares in a Newborn?

Y'all volition recognize priority questions on the NCLEX-RN® exam because they will ask you what is the "best," "most important," "first," or "initial response" past the nurse.

As you read this question you are probably thinking, "All of these look right!" or "How can I make up one's mind what I volition do first?" The panic sets in equally y'all try to make up one's mind what the all-time reply is when they all seem "correct."

As a registered professional nurse, you volition be caring for clients who accept multiple bug and needs. You must exist able to establish priorities by deciding which needs take precedence over the other needs. You lot probably recognized the baby's hasty movements as an indication of hypoglycemia. Don't forget that an important role of the assessment procedure is validating what you detect. You must complete an cess before you analyze, plan, and implement nursing care.

The correct answer is (3).

The critical thinking required for priority questions is for you to recognize patterns in the answer choices. By recognizing these patterns, you lot volition know which path you need to cull to correctly reply the question.

There are three strategies to help yous plant priorities on the NCLEX-RN® exam:

• Maslow strategy
• Nursing process strategy
• Safety strategy

We will outline each strategy, draw how and when information technology should exist used, and show you how to utilise these strategies to exam-manner questions. Past using these strategies, you will be able to eliminate the second-all-time answer and correctly identify the highest priority.

Adept Exam Tip

Jo Ann Scipio, NCLEX Instructor

"Consider and visualize each question equally a clinical situation."

NCLEX Question Strategy One: Maslow

Maslow's hierarchy of needs (Figure 1) is crucial to establishing priorities on the NCLEX-RN® exam. Maslow identifies five levels of homo needs: physiological, safe or security, love and belonging, esteem, and cocky-actualization.

Because physiological needs are necessary for survival, they accept the highest priority and must be met showtime. Physiological needs include oxygen, fluid, nutrition, temperature, elimination, shelter, balance, and sex. If you lot don't have oxygen to exhale or nutrient to eat, you really don't care if y'all have stable psychosocial relationships!

Prophylactic and security needs can exist both concrete and psychosocial. Physical safety includes decreasing what is threatening to the client. The threat may be an illness (myocardial infarction), accidents (a parent transporting a newborn in a car without using a car seat), or environmental threats (the client with COPD who insists on walking outside in 10° F [−12° C] temperatures).

To reach psychological safety, the client must have the noesis and understanding about what to expect from others in his environment. For example, it is of import to teach the client and his family what to wait later a cerebrovascular blow (CVA). Information technology is also important that you permit a adult female preparing for a mastectomy to verbalize her concerns most changes that might occur in her human relationship with her partner.

To attain love and belonging, the client needs to feel loved by family and accepted by others. When a client feels self-confident and useful, he will achieve the demand of self-esteem as described by Maslow.

The highest level of Maslow's hierarchy of needs is self-actualization. To achieve this level, the client must experience fulfillment and recognize his or her potential. In order for cocky-actualization to occur, all of the lower-level needs must be met. Considering of the stresses of life, lower-level needs are not always met, and many people never achieve this loftier level of functioning.

The Maslow Four-Step Process

The outset strategy to apply in establishing priorities is a four-pace process, beginning with Maslow's hierarchy. To use the Maslow strategy, you lot must first recognize the pattern in the respond choices.

  • Footstep 1

    Look at your respond choices. Determine if the answer choices are both physiological and psychosocial. If they are, utilise the Maslow strategy detailed in Footstep 2.

  • Pace ii

    Eliminate all psychosocial answer choices. If an answer choice is physiological, don't eliminate it nonetheless. Remember, Maslow states that physiological needs must be met get-go. Although pain certainly has a physiological component, reactions to pain are considered "psychosocial" on this examination and will get a lower priority.

  • Step iii

    Look at each of the answer choices that you have non yet eliminated and ask yourself if the reply pick makes sense with regard to the disease or state of affairs described in the question. If it makes sense every bit an respond choice, keep it for consideration and go on to the next choice.

  • Step 4

    Look at the remaining answer choices. Tin can you apply the ABCs? The ABCs stand for airway, breathing, and circulation. If at that place is an answer that involves maintaining a patent airway, it will be correct. If non, is there a pick that involves animate problems? Information technology will be correct. If not, get on with the ABCs.

    Is there an answer pertaining to the cardiovascular arrangement? It will exist right. What if the ABCs don't employ? Compare the remaining respond choices and ask yourself, "What is the highest priority?" This is your answer.


Use the Maslow Four-Step Process to answer this practice question.

NCLEX Question Strategy Two: Nursing Procedure (Assessment versus Implementation)

A 2nd strategy that will assist you in establishing priorities involves the cess and implementation steps of the nursing process. As a nursing pupil, you lot take been drilled so that you can recite the steps of the nursing procedure in your sleep—cess, analysis, planning, implementation, and evaluation. In nursing school, you did have some test questions about the nursing procedure, just y'all probably did not apply the nursing procedure to assist you in selecting a right reply on an exam.

On the NCLEX-RN® test, you volition be given a clinical state of affairs and asked to establish priorities. The possible answer choices will include both the correct assessment and implementation for this clinical situation. How do you choose the right reply when both the correct assessment and implementation are given? Think most these two steps of the nursing process.

Assessment is the process of establishing a data contour near the client and his or her health problems. The nurse obtains subjective and objective data in a number of means: talking to clients, observing clients and/or pregnant others, taking a health history, performing a physical examination, evaluating lab results, and collaborating with other members of the wellness intendance team.

One time you collect the information, yous compare it to the customer's baseline or normal values. On the NCLEX-RN® examination, the client'south baseline may non be given, simply as a nursing student you lot have caused a body of knowledge. On this test, you are expected to compare the client data you are given to the "normal" values learned from your nursing textbooks.
Assessment is the commencement step of the nursing procedure and takes priority over all other steps. It is essential that yous complete the assessment phase of the nursing process earlier you implement nursing activities. This is a common mistake made by NCLEX-RN® exam takers: don't implement earlier you assess.

For example, when performing cardiopulmonary resuscitation (CPR), if y'all don't admission the airway earlier performing rima oris-to-mouth resuscitation, your actions may be harmful!

Implementation is the care you provide to your clients. Implementation includes: assisting in the performance of activities of daily living (ADLs), counseling and educating the client and the client'south family, giving care to clients, and supervising and evaluating the work of other members of the wellness team. Nursing interventions may be independent, dependent, or interdependent. Independent interventions are inside the scope of nursing practice and exercise not require supervision by others. Instructing the customer to turn, cough, and breathe deeply after surgery is an case of an independent nursing intervention. Dependent interventions are based on the written orders of a doc. On the NCLEX-RN® exam, you should assume that yous have an order for all dependent interventions that are included in the answer choices.

This may be a different way of thinking from the way you lot were taught in nursing schoolhouse. Many students select an answer on a nursing school exam (that is later counted incorrect) because the intervention requires a medico'south society. Everyone walks abroad from the examination review muttering, "Trick question." Information technology is important for you to remember that there are no trick questions on the NCLEXRN® exam. You should base your answer on an agreement that you take a physician's society for whatsoever nursing intervention described.

Interdependent interventions are shared with other members of the health team. For instance, diet pedagogy may be shared with the dietitian. Chest physiotherapy may be shared with a respiratory therapist.

The following strategy, utilizing the assessment and implementation phases of the nursing process, will assist you in selecting correct answers to questions that ask you to identify priorities.

  • Step 1

    Read the reply choices to establish a design. If the answer choices are a mix of cess/validation and implementation, use the Nursing Process (Assessment vs. Implementation) strategy.

  • Footstep 2

    Refer to the question to determine whether you should be assessing or implementing.

  • Footstep iii

    Eliminate answer choices, and and so choose the all-time answer.

    If after Step 2 you observe that, for example, information technology is an cess question, eliminate whatsoever answers that clearly focus on implementation. Then cull the all-time assessment answer.


Use the Nursing Process to answer this practice question.

NCLEX Question Strategy Three: Condom

Nurses have the primary responsibility of ensuring the safe of clients. This includes clients in wellness intendance facilities, in the home, at work, and in the customs. Prophylactic includes: meeting basic needs (oxygen, nutrient, fluids, etc.), reducing hazards that cause injury to clients (accidents, obstacles in the dwelling house), and decreasing the transmission of pathogens (immunizations, sanitation).

Call up that the NCLEX-RN® test is a test of minimum competency to determine that you lot are able to practice safe and effective nursing care. Always remember rubber when selecting right answers on the test. When answering questions about procedures, this strategy volition assist you lot to establish priorities.


  • Step 1

    Are all the reply choices implementations? If so, utilise the Safety strategy illustrated above.

  • Pace ii

    Tin can you answer the question based on your knowledge? If non, proceed to Step iii.

  • Step iii

    Ask yourself, "What volition crusade the client the least corporeality of impairment?" and cull the best respond.

Apply the saftey strategy higher up to the following question.

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Source: https://www.kaptest.com/study/nclex/nclex-question-strategies-priority-questions/

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