nclex question strategies priority questions

NCLEX Question Strategies: Priority Questions

You will recognize priority questions on the NCLEX-RN® exam because they will ask you what is the “best,” “most important,” “first,” or “initial response” by the nurse.

Take a look at this sample question.

 

An hour after admission to the nursery, the nurse observes a newborn baby having spontaneous jerky movements of the limbs. The infant’s mother had gestational diabetes mellitus (GDM) during pregnancy. Which of the following actions should the nurse take FIRST? 

1. Give dextrose water.

2. Call the physician immediately.

3. Determine the blood glucose level.

4. Observe closely for other symptoms.

As you read this question you are probably thinking, “All of these look right!” or “How can I decide what I will do first?” The panic sets in as you try to decide what the best answer is when they all seem “correct.”

As a registered professional nurse, you will be caring for clients who have multiple problems and needs. You must be able to establish priorities by deciding which needs take precedence over the other needs. You probably recognized the baby’s jerky movements as an indication of hypoglycemia. Don’t forget that an important part of the assessment process is validating what you observe. You must complete an assessment 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 will know which path you need to choose to correctly answer the question. There are three strategies to help you establish priorities on the NCLEX-RN® exam:

• Maslow strategy

• Nursing process strategy

• Safety strategy

We will outline each strategy, describe how and when it should be used, and show you how to apply these strategies to exam-style questions. By using these strategies, you will be able to eliminate the second-best answer and correctly identify the highest priority.

 

Expert Test Tip

Jo Ann Scipio, NCLEX Instructor

“Consider and visualize each question as a clinical situation.”

 

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 human needs: physiological, safety or security, love and belonging, esteem, and self-actualization.

Because physiological needs are necessary for survival, they have the highest priority and must be met first. Physiological needs include oxygen, fluid, nutrition, temperature, elimination, shelter, rest, and sex. If you don’t have oxygen to breathe or food to eat, you really don’t care if you have stable psychosocial relationships!

Safety and security needs can be both physical 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 attain psychological safety, the client must have the knowledge and understanding about what to expect from others in his environment. For example, it is important to teach the client and his family what to expect after a cerebrovascular accident (CVA). It is also important that you allow a woman preparing for a mastectomy to verbalize her concerns about changes that might occur in her relationship with her partner.

To achieve 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 need 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 self-actualization to occur, all of the lower-level needs must be met. Because of the stresses of life, lower-level needs are not always met, and many people never achieve this high level of functioning.

 

The Maslow Four-Step Process

The first strategy to use in establishing priorities is a four-step process, beginning with Maslow’s hierarchy. To use the Maslow strategy, you must first recognize the pattern in the answer choices.

  • Step 1

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

  • Step 2

    Eliminate all psychosocial answer choices. If an answer choice is physiological, don’t eliminate it yet. Remember, Maslow states that physiological needs must be met first. Although pain certainly has a physiological component, reactions to pain are considered “psychosocial” on this exam and will become a lower priority.

  • Step 3

    Look at each of the answer choices that you have not yet eliminated and ask yourself if the answer choice makes sense with regard to the disease or situation described in the question. If it makes sense as an answer choice, keep it for consideration and go on to the next choice.

  • Step 4

    Can you apply the ABCs? Look at the remaining answer choices. Can you apply the ABCs? The ABCs stand for airway, breathing, and circulation. If there is an answer that involves maintaining a patent airway, it will be correct. If not, is there a choice that involves breathing problems? It will be correct. If not, go on with the ABCs. Is there an answer pertaining to the cardiovascular system? It will be correct. What if the ABCs don’t apply? Compare the remaining answer choices and ask yourself, “What is the highest priority?” This is your answer.

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

The nurse obtains a diet history from a pregnant 16-year-old girl. The girl tells the nurse that her typical daily diet includes cereal and milk for breakfast, pizza and soda for lunch, and a cheeseburger, milk shake, fries, and salad for dinner. Which of the following is the MOST accurate nursing diagnosis based on this data?

1. Altered nutrition: more than body requirements related to high-fat intake

2. Knowledge deficit: nutrition in pregnancy

3. Altered nutrition: less than body requirements related to increased nutritional
demands of pregnancy

4. Risk for injury: fetal malnutrition related to poor maternal diet

Answer and Explanation

The first thing you should notice about this question stem is the phrase “most accurate.” This alerts you that there may be more than one answer choice that could be considered correct.

Step 1. Look at the answer choices. You will see that both physical and psychosocial interventions are included. Apply the Maslow strategy.

Step 2. Eliminate all psychosocial answer choices. In this case, that means answer choice (2). Knowledge deficit is a psychosocial need.

Step 3. Ask yourself whether the remaining answer choices make sense.

(1) “Altered nutrition: more than body requirements related to high-fat intake” does make sense. This diet is high in fat.

(3)  “Altered nutrition: less than body requirements related to increased nutritional demands of pregnancy” also makes sense. This diet has an adequate number of calories, but it is deficient in the needed vitamins and minerals.

(4)  “Risk for injury: fetal malnutrition related to poor maternal diet” does not make sense. There is an adequate number of calories to support fetal growth. Eliminate this choice.

You have now eliminated two of the choices. Let’s go on.

Step 4. Answer choices (1) and (3) remain. Can you apply the ABCs to these choices? No. So compare the answer choices. Which is higher priority: the fact that this pregnant 16-year-old’s diet contains too much fat, or that the diet does not have enough nutrients? Insufficient nutrients is a higher priority, so the correct answer is (3).

Many students, when they first read this question, choose (2), knowledge deficit. According to Maslow, physiological needs always take priority over psychosocial needs. Using this strategy on the NCLEX-RN® exam will enable you to choose the correct answer.

 

Strategy Two: Nursing Process (Assessment versus Implementation)

 

A second strategy that will assist you in establishing priorities involves the assessment and implementation steps of the nursing process. As a nursing student, you have been drilled so that you can recite the steps of the nursing process in your sleep—assessment, analysis, planning, implementation, and evaluation. In nursing school, you did have some test questions about the nursing process, but you probably did not use the nursing process to assist you in selecting a correct answer on an exam.

On the NCLEX-RN® exam, you will be given a clinical situation 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 correct answer when both the correct assessment and implementation are given? Think about these two steps of the nursing process.

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

Once you collect the data, you compare it to the client’s baseline or normal values. On the NCLEX-RN® exam, the client’s baseline may not be given, but as a nursing student you have acquired a body of knowledge. On this exam, you are expected to compare the client information you are given to the “normal” values learned from your nursing textbooks.

Assessment is the first step of the nursing process and takes priority over all other steps. It is essential that you complete the assessment phase of the nursing process before you implement nursing activities. This is a common mistake made by NCLEX-RN® exam takers: don’t implement before you assess. For example, when performing cardiopulmonary resuscitation (CPR), if you don’t access the airway before performing mouth-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’s family, giving care to clients, and supervising and evaluating the work of other members of the health team. Nursing interventions may be independent, dependent, or interdependent. Independent interventions are within the scope of nursing practice and do not require supervision by others. Instructing the client to turn, cough, and breathe deeply after surgery is an example of an independent nursing intervention. Dependent interventions are based on the written orders of a physician. On the NCLEX-RN® exam, you should assume that you 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 were taught in nursing school. Many students select an answer on a nursing school test (that is later counted wrong) because the intervention requires a physician’s order. Everyone walks away from the test review muttering, “Trick question.” It is important for you to remember that there are no trick questions on the NCLEXRN® exam. You should base your answer on an understanding that you have a physician’s order for any nursing intervention described.

Interdependent interventions are shared with other members of the health team. For instance, nutrition education 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 answer choices to establish a pattern. If the answer choices are a mix of assessment/validation and implementation, use the Nursing Process (Assessment vs. Implementation) strategy.

  • Step 2

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

  • Step 3

    Eliminate answer choices, and then choose the best answer.

    If after Step 2 you find that, for example, it is an assessment question, eliminate any answers that clearly focus on implementation. Then choose the best assessment answer.

Use the Nursing Process to answer this practice question.

A 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 and conscious, but in severe pain with a possible fracture of the right femur. Which of the following is the FIRST action that the nurse should take?

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

2. Make a thorough assessment of the circumstances surrounding the accident.

3. Put him in semi-Fowler’s position for comfort.

4. Check the pedal pulse and blanching sign in both legs.

Answer and Explanation

The words “ first action” tell you that this is a priority question.

The Reworded Question: What is the highest priority for a fractured femur?

Step 1. Read the answer choices to establish a pattern.

The answer choices are a mix of assessment/validation and implementation. Use the Nursing Process (Assessment vs. Implementation) strategy.

Step 2. Refer to the question to determine whether you should be assessing or implementing. According to the question, the nurse has determined that the boy has a possible fracture.

This implies that the nurse has completed the assessment step. It is now time to implement.

Step 3. Eliminate answer choices, and then choose the best answer.

Eliminate answers (2) and (4) because they are assessments. This leaves you with choices (1) and (3). Which takes priority: immobilizing the affected limb, or placing the boy in a semi-Fowler’s position to facilitate breathing? The question does not indicate any respiratory distress. The correct answer is (1), immobilize the affected limb.

Some students will choose an answer involving the ABCs without thinking it through. Students, beware. Use the ABCs to establish priorities, but make sure that the answer is appropriate to the situation. In this question, breathing was mentioned in one of the answer choices. If you thought of the ABCs immediately without looking at the context of the question, you would have answered this question incorrectly.

 

Strategy Three: Safety

Nurses have the primary responsibility of ensuring the safety of clients. This includes clients in health care facilities, in the home, at work, and in the community. Safety includes: meeting basic needs (oxygen, food, fluids, etc.), reducing hazards that cause injury to clients (accidents, obstacles in the home), and decreasing the transmission of pathogens (immunizations, sanitation).

Remember that the NCLEX-RN® exam is a test of minimum competency to determine that you are able to practice safe and effective nursing care. Always think safety when selecting correct answers on the exam. When answering questions about procedures, this strategy will help you to establish priorities.

  • Step 1

    Are all the answer choices implementations? If so, use the Safety strategy illustrated above.

  • Step 2

    Can you answer the question based on your knowledge? If not, continue to Step 3.

  • Step 3

    Ask yourself, “What will cause the client the least amount of harm?” and choose the best answer.

Apply this strategy to the following question.

A child undergoes a tonsillectomy for treatment of chronic tonsillitis unresponsive to antibiotic therapy. After surgery, the child is brought to the recovery room. Which of the following actions should the nurse include in the child’s plan of care?

1. Institute measures to minimize crying.

2. Perform postural drainage every 2 hours.

3. Cough and deep-breathe every hour.

4. Give ice cream as tolerated.

Answer and Explanation

The Reworded Question: What should you do after a tonsillectomy? Step 1. Are all the answer choices implementations? Yes.

Step 2. Can you answer the question based on your knowledge of a tonsillectomy? If not, continue to Step 3.

Step 3. Ask yourself, “What will cause the client the least amount of harm?”

Answer choice (1), minimizing crying, will help prevent bleeding. Keep in consideration. Answer choice (2), postural drainage, may cause bleeding. Eliminate. Answer choice (3), coughing and deep-breathing, may cause bleeding. Eliminate. Answer choice (4), giving ice cream, may cause the child to clear his throat, causing bleeding. Eliminate. The correct answer is (1). The nurse must prevent postoperative hemorrhage, a complication seen after this type of surgery. Crying would irritate the child’s throat and increase the chance of hemorrhage.