A client with a temperature of 100°F (37.8°C).
In the absence of other symptoms, obtain a prescription for an antipyretic and monitor the client until the client can be evaluated by the health care provider. A delay in care will not harm this client.
A client reporting arm pain after falling off a chair.
Assess the neurovascular status of the effected extremity, then ice, splint, and elevate it until the client can be evaluated by the health care provider. A delay in care will not harm this client.
A client reporting vomiting for the past several hours.
In the absence of comorbidities, the average adult?s body can adequately compensate for dehydration over the short term. A delay in care will not harm this client.
A client with a persistent nosebleed. (Correct Answer)
Compromised circulation takes precedence over the other clients' needs.
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
- A client with a temperature of 100°F (37.8°C). Stable. Eliminate.
- A client reporting arm pain after falling off a chair. Stable. Eliminate.
- A client reporting vomiting for the past several hours. Unstable
- A client with a persistent nosebleed. Unstable
Unexpected vs. Expected
3. A client reporting vomiting for the past several hours. Unexpected
4. A client with a persistent nosebleed. Unexpected
ABCs
3. A client reporting vomiting for the past several hours. Circulation. Eliminate.
4. A client with a persistent nosebleed. Airway/Circulation
Select the best choice
Is #4 the correct answer? Yes, the most unstable client will be assessed first.
Does #4 make sense? Yes, a persistent nosebleed is an airway risk and, if severe enough, has the potential for hypovolemia. This can lead to orthostatic hypotension and is a safety concern.
