An older adult client admitted 4 days ago with a diagnosis of a stage 3 pressure injury.
A stage 3 pressure injury entails full-thickness skin loss involving damage or necrosis of subcutaneous tissue. The client requires aggressive treatment.
An older adult client admitted 12 hours ago with a diagnosis of pyelonephritis.
Pyelonephritis is a bacterial infection of the kidney. It is treated with intravenous antibiotics. The client is at high risk for sepsis.
An older adult client 3 days postoperative after a total hip replacement. (Correct Answer)
This is the most stable client. Clients post-total hip replacement are typically discharged on postoperative day 2 to 3 to a rehab facility or home.
An adult client 24 hours postoperative after a vaginal hysterectomy.
This is the second most stable client. There is a risk for bleeding, but clients post-vaginal hysterectomy are typically discharged 48 hours post-surgery.
Decision Tree:
This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.
This is a "Who Do You See First" Question.
Terminology that is used here is often phrased as, "Who does the nurse see first?" Use these steps, based on the Kaplan Decision Tree, to determine the correct answer.
STEP 1: Can you identify the topic of the question?
STEPS 2-4: These steps are not relevant to this type of question because you do not need to use the rules for Who Do You See First questions. Move to Step 5.
STEP 5: Read each answer choice and use the Who Do You See First rules.
Who Do You See First Rules:
- Is the client stable or unstable? Eliminate the stable clients.
- Is the client experiencing an expected or unexpected finding? Eliminate expected findings.
- Are the remaining answer options referring to airway, breathing, or circulation (ABCs)? Eliminate each non-priority answer option using the ABCs.
- Are the remaining answers options referring to acute or chronic situations? Eliminate the chronic situation answer options.
- Are the remaining answer options real (actual) or potential problems? Eliminate the potential problem answer options.
- Look at each answer option that remains and ask, what outcome do you want for this client?
- Does this answer option make sense in this situation? If yes, keep this answer option.
- Will this answer option help the client? If yes, keep this answer option.
- Will this answer option hurt the client? If yes, eliminate this answer option.
Unstable vs. Stable
- An older adult client admitted 4 days ago with a diagnosis of a stage 3 pressure injury. Unstable. Eliminate.
- An older adult client admitted 12 hours ago with a diagnosis of pyelonephritis. Unstable. Eliminate.
- An older adult client 3 days postoperative after a total hip replacement. Stable
- An adult 24 hours postoperative after a vaginal hysterectomy. Stable
Unexpected vs. Expected
3. An older adult client 3 days postoperative after a total hip replacement. N/A
4. An adult 24 hours postoperative after a vaginal hysterectomy. N/A
ABCs
3. An older adult client 3 days postoperative after a total hip replacement. Not ABC.
4. An adult 24 hours postoperative after a vaginal hysterectomy. Circulation. Eliminate.
Select the best choice
Is #3 the correct answer? Yes, the most stable client will be discharged.
Does #3 make sense? Yes, clients with a total hip replacement are transferred to a rehabilitation facility or discharged to home 2 to 3 days after surgery.
