Recognize Expected Outcomes

You spent much of your time in practical/vocational nursing school learning about what might go wrong with clients and their care. This makes sense; after all, nurses need to deal with problems and illnesses. Many test questions that your practical/vocational nursing school faculty wrote focused on what was wrong with clients and their care. In order to prove minimum competence, the beginning practical/vocational nurse must demonstrate the ability to make appropriate nursing judgments. Competent nursing judgments include recognizing both expected and unexpected behaviors, so it is important for you to recognize expected outcomes on the NCLEX-PN^® exam. Expected outcomes are the behaviors and changes you think are going to occur as a result of nursing care. These outcomes allow the nurse to evaluate whether goals have been met.

Look at the following question.

The LPN/LVN is checking the morning’s serum electrolyte results for a client. The LPN/LVN notes that the client’s sodium is 142 mEq/L (142 mmol/L), potassium is 4.4 mEq/L (4.4 mmol/L), and chloride is 102 mEq/L (102 mmol/L). Which of the following should the nurse do first?
1. Encourage the client to drink additional fluids.
2. Notify primary health care provider of electrolyte results.
3. Record electrolyte results in the client's medical record.
4. Withhold the client’s potassium supplement.

If this question were included on one of your fundamentals tests, you would assume that a problem was being described. You would choose an answer that involved “fixing” the problem. Let’s look at this question.

THE REWORDED QUESTION: What should you do with a client with these electrolyte results?

Step 1. Recognize normal. Interpret the serum electrolyte results. All are within normal limits.

Step 2. Decide how you should use this information. Because the values are all normal, let’s reword the question again using this information.

Now THE REWORDED QUESTION is: What should you do for a client with normal serum electrolytes?

ANSWERS:

Encourage the client to drink additional fluids. Although good fluid intake is usually recommended, this is not a priority because the serum electrolytes are within normal limits. Eliminate.
Notify the physician of the client’s electrolyte results. This is unnecessary because the serum electrolytes are normal. Most physicians request notification only for abnormal test results. Eliminate.
Record the electrolyte results in the client’s chart. This action should be done because the electrolyte results are normal.
Withhold the client’s morning potassium supplement. The client’s K⁺ is within normal limits, which suggests that the potassium supplement has helped maintain this serum level. There is no indication with the information you have been given that this would be necessary or prudent. Eliminate.

The correct answer is (3). The electrolytes are within normal limits. Some students select answer choice (1) because they think there’s something they missed, or it must be a trick question. The “trick” is deciding whether the information that you are given is normal or abnormal, and then answering the question accordingly.

Try this question.

A client reporting chest pressure is brought to the emergency department (ED). Vital signs include blood pressure is 150/90 mm Hg, pulse 88 beats/minute, respirations 20 breaths/minute. The LPN/LVN administers nitroglycerin 0.4 mg sublingually as ordered. After five minutes, the client’s vital signs include, blood pressure is 100/60 Hg, pulse 96 beats/minute, respirations 20 breaths/minute. Which of the following actions should the LPN/LVN take next?
1. Notify the primary health care provider of hypotension.
2. Place the client in semi-Fowler’s position and administer oxygen at 4 L/minute.
3. Administer a second dose of nitroglycerin 0.4 mg sublingually, as ordered.
4. Document vital signs and continue to monitor the client.

THE REWORDED QUESTION: What should you do for this client?

To answer this question you need to know what these vital signs indicate.

Step 1. Recognize normal. Nitroglycerin is a potent vasodilator with anti-anginal, anti-ischemic, and antihypertensive actions. It increases blood flow through the coronary arteries. Side effects include orthostatic hypotension, tachycardia, dizziness, and palpitations. Decreased blood pressure, increased pulse rate, and stable respiratory rate after administration of a potent vasodilator is normal and expected.

Step 2. Decide how you should use this information. The question should be reworded as, “What should you do for a client who has responded as expected to a dose of nitroglycerin?”

ANSWERS:

Notify the primary health care provider of hypotension. The blood pressure has decreased due to vasodilation. Decreased blood pressure is expected. Eliminate.
Place the client in semi-Fowler’s position and administer oxygen at 4L/minute. Respiratory rate is stable and there is no indication of respiratory distress. Eliminate.
Administer a second dose of nitroglycerin 0.4 mg sublingually, as ordered. The nurse should assess the client for chest pain first, and administer a second dose of the medication only if the client continues to report chest pain. Eliminate.
Document the vital signs and continue to closely monitor the client. This is the correct choice. You identified it by recognizing the client’s response as normal, thus eliminating the other three answer choices.

The correct answer is (4). You would expect a client’s blood pressure to decrease after administration of nitroglycerin. The key to this question is understanding how the medication works and correctly identifying the expected outcome.