NCLEX Test-Taking Strategy Tip

Tip #6: Identify the step in the nursing process being tested.

Remember, you must have adequate assessment data before you move through the steps of the nursing process. Is there adequate information presented in the stem of the question to determine appropriate nursing planning or intervention? Is the correct nursing action to obtain further assessment data? Look for key words that can assist you in determining what type of information is being requested.

Example: An 85-year-old client from a residential care facility is brought into the emergency department. Numerous bruises and abrasions in various stages of healing are present on the client's face and arms. The attendant from the residential facility explains that the client fell down. What is the priority nursing action?

1. Call the residential facility and ask for an incident report.
2. Put ice on the bruises and cover the abrasions with protective gauze.
3. Notify the supervisor regarding the possibility of an abusive situation.
4. Perform a head-to-toe assessment and determine the extent of the injuries.

The correct answer is 4, to determine or assess the extent of injuries. The stem of the question did not present adequate information with which to make a nursing judgment, and the client's physiologic needs are the priority. Option 1 does not immediately alleviate pain or assist the client. Options 2 and 3 relate to nursing actions that may be done after the immediate injuries
and needs have been assessed. Focus on the client; priority setting and physiologic needs must be addressed first.

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