Strategy Three: Safety

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LPN/LVNs 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-PN^® 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 my client the least amount of harm?” and choose the best answer.

Apply this strategy to the following question.

1. A child undergoes a tonsillectomy for treatment of chronic tonsillitis unresponsive to antibiotic therapy. After surgery, the child is brought to the clinical unit. Which of the following actions should the LPN/LVN include in his 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.

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. Coughing and deep-breathing (3) may cause bleeding. Eliminate. Giving ice cream (4) 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.

Let’s try another question.

1. The LPN/LVN doubts the accuracy of a drug order on the medication administration record. Which of the following actions should the LPN/LVN take FIRST?
   1. Compare the drug order on the medication administration record with the physician’s order sheet.
   2. Contact the prescribing physician.
   3. Consult with the pharmacist.
   4. Look up the medication in a nursing drug book.

THE REWORDED QUESTION: What should you do if you think the medication administration record (MAR) is incorrect?

Step 1. Are all the answers implementations?

Yes.

Step 2. Ask yourself the question, “What will protect my client the most?”

1. Comparing the MAR with the original physician’s order would certainly provide clarification regarding the questioned medication. Leave this choice for consideration.
2. Calling the prescribing physician would certainly help clarify the order, but this should not be the first step. Eliminate.
3. Consulting the pharmacist can shed light on a medication, but the LPN/LVN first needs to know what the original order said. Eliminate.
4. Looking up the medication in a nursing drug book is a good idea, but will this step help the LPN/LVN if the original order was incorrectly written on the MAR? Eliminate.

Only choice (1) is left for consideration and is the correct answer. The NCLEX-PN^® test makers want to know what decision you are going to make to protect your client, not what decision the physician will make.

Let’s look at another question.

1. A client is admitted with a diagnosis of dementia. He attempts several times to pull out his nasogastric tube. An order for cloth wrist restraints is received by the LPN/LVN. Which of the following actions by the LPN/LVN is MOST appropriate?
   1. Attach the ties of the restraints to the bed frame.
   2. Perform range of motion to the restrained extremities once a shift.
   3. Remove the restraints when the client is up in a wheelchair.
   4. Explain the need for restraints only to the family because the client is confused.

THE REWORDED QUESTION: “What is the safest way to apply restraints?”

Step 1. Are all answers implementations?

Yes.

Step 2. Can you answer this based on your knowledge?

If not, proceed to Step 3.

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

(1) Attaching the ties of the restraint to the bed frame will not harm the client. Retain this answer.

(2) Performing range of motion once a shift will not harm the client. However, it should be performed more frequently. Retain this answer.

(3) Removing the restraints when the client is up in a wheelchair will be harmful to the client. Restraints should not be removed when the client is unattended. Eliminate.

(4) Explaining the need for restraints only to the family can cause harm to the client. Restraints can increase the confusion or combativeness of the client. Even though the client is confused, he needs to receive an explanation. Eliminate.

You are now considering answer choices (1) and (2). What will cause the least amount of harm to the client—attaching the ties of the restraint to the bed frame or performing range of motion to the extremities once a shift? Range of motion should be performed every 2–4 hours to prevent loss of joint mobility. Eliminate (2). The correct answer is (1). Attaching the ties of the restraint to the bed frame will allow the nurse to raise and lower the side rail without injury to the client.

Priority questions are an important component of the NCLEX-PN^® exam. To help you select correct answers, think:

• Maslow
• The Nursing Process
• Safety

Answer the following three questions using the appropriate priority strategy. The explanations follow the questions.

Question 1

1. The LPN/LVN cares for a client with a diagnosis of stroke. The LPN/LVN is feeding the client in a chair when he suddenly begins to choke. Which of the following actions should the LPN/LVN take FIRST?
   1. Check for breathlessness by placing an ear over the client’s mouth and observing the chest.
   2. Leave the client in the chair and apply vigorous abdominal or chest thrusts from behind the client.
   3. Ask the client, “Are you choking?”
   4. Return the client to the bed and apply vigorous abdominal or chest thrusts while straddling the client’s thighs.

Question 2

1. A client with a history of bipolar disorder is admitted to the psychiatric hospital. She was found by the police attempting to climb onto the wing of a plane at the airport. Her husband reports that she has not eaten or slept in 2 days, and he suspects she has stopped taking lithium. On admission, the LPN/LVN should place the HIGHEST priority on which of the following client care needs?
   1. Teaching the client about the importance of taking lithium as prescribed
   2. Providing the client with a safe environment with few distractions
   3. Arranging for food and rest for the client
   4. Setting limits on the client’s behavior

Question 3

1. The physician orders a nasogastric (NG) tube inserted and connected to low intermittent suction for a client with an intestinal obstruction. Two hours after the insertion of the NG tube, the client vomits 200 mL. While irrigating the NG tube, the LPN/LVN notes resistance. Which of the following actions should the LPN/LVN take FIRST?
   1. Replace the NG tube with a larger one.
   2. Turn the client on his left side.
   3. Change the suction from intermittent to continuous.
   4. Continue the irrigation.

Let’s see if you were able to correctly determine which strategy you should use to determine priorities.

Question 1

The answer choices include both data collection and implementations. Use the Nursing Process strategy to select the correct answer.

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

Choices (1) and (3) are data collection; choices (2) and (4) are implementations.

Step 2. Refer to the question to determine whether you should be collecting data or implementing. According to the situation, the client has begun to choke. This alerts the nurse that there is a problem. The first step of the nursing process is data collection.

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

Eliminate answer choices (2) and (4) because they are implementations. Now choose the best answer from the remaining answer choices, (1) and (3).

What takes priority—assessing for breathlessness by placing an ear over the client’s mouth or assessing the client by asking, “Are you choking?” Inability to speak or cough indicates the airway is obstructed. Breathlessness should be checked only in an unconscious client. The correct answer is (3).

Question 2

Look at the answer choices. They include both physiological and psychosocial interventions. Apply the Maslow strategy.

Step 1. Look at the answer choices and identify which are physiological—choices (2) and (3)—and which are psychosocial—choices (1) and (4).

Step 2. Eliminate all psychosocial answer choices—(1) and (4).

Step 3. Ask yourself if the remaining answer choices make sense. Choice (2), providing the client with a safe environment, does make sense. Retain this answer. Choice (3), arranging for food and rest, also makes sense. Retain this answer.

Step 4. Can you apply the ABCs to the remaining answer choices? No; neither choice refers to airway, breathing, or circulation. Since the ABCs don’t apply, ask yourself “What is the highest priority—providing for a safe environment, or providing for food and rest?” According to Maslow, food and rest take highest priority. The correct answer is (3).

Question 3

This question is about a procedure: What should the nurse do when resistance is met while irrigating an NG tube? If you are unsure about a procedure, think safety.

Step 1. Read the answer choices to establish a pattern. Are all the answer choices implementations? Yes.

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?”

1. Replacing the NG tube with a larger one could harm the client by damaging the mucosa. Eliminate.
2. Turning the client to his left side would not hurt the client. Retain this answer choice.
3. Changing the suction from intermittent to continuous is never done because it will erode the mucosa. Eliminate.
4. Continuing the irrigation when there is resistance might be harmful. Never force an irrigation. Eliminate.

The correct answer is (2). The tip of the tube may be against the stomach wall. Repositioning the client might allow the tip to lie unobstructed in the stomach.

Using the critical thinking strategies outlined in this chapter will help you unlock the secrets of correctly answering priority questions.