Walkthrough: Health Promotion and Maintenance Q3 – NCLEX-RN®

00:00 Let's take a look at the stem of this question. I know it takes every fiber of your being not to jump down to those answer choices but don't do it. Okay, stay with us.

00:12 Focus, focus, focus. Look at this stem. The nurse is auscultating the fetal heart tone of a client who is 35 weeks gestation. Suddenly, the client complains of feeling hot, dizzy, and nauseous. Which is the nurse's first intervention? Don't you do it, don't go on to those answer choices. Let's do the work in the stem first. So let's go back through the first sentence. Right? The nurse is auscultating the fetal heart tone, so I have a picture of what that looks like, of a client who is 35 weeks gestation. Okay, so they're close to the end but they're not quite there. So sentence 1, a nurse auscultating fetal heart tones on a 35 weeks gestation client.

01:00 Suddenly, alright. Why am I saying that word that way? Because here's a buzz word, an NCLEX testing word or buzz word. When you see it, it indicates there's a change. Okay, so that means they're trying to test if you recognize this is a change and is it a problem or is it put the patient in danger and what should you do.

01:26 So sentence number 2, suddenly the client complains. Whoah, there is another thing, the client complains. Anytime a client communicates something to you, that's very important to the question. So the client complains of feeling hot. Well that's an assessment. So you always ask yourself when you see an assessment "Is that normal or abnormal." It is not normal to feel hot. What about they feel dizzy? Is that normal? No, that's not normal. What about nauseous? No, that's not normal.

02:05 So what I know so far is that I have, I was auscultating fetal heart tones of a client who's 35 weeks gestation, suddenly the client complains of some abnormal assessment. Which is the nurse's first intervention? I like to call that word the other F word. Okay, so which is the nurse's first intervention. It's a really important keyword because it's telling you what do I do first. That's different than what is most important that I do or am I going to do any of these other interventions.

02:42 Those are all possibilities, but that last sentence is your final focus. Put this question into your own words. When I'm auscultating fetal heart tones of a 35-week gestation client, suddenly they have some abnormal changes. They feel hot, dizzy, and nauseous. What should I do first? Okay, now we're on to the answer choices.

03:06 So we'll show you those. I want you to read through the answer choices. Write down 1, 2, 3 and 4, the numbers, not the words, just the numbers on a scratch piece of paper. And then I want you to work through those answers on your own.

03:22 Remember, you're going to eliminate 3 of these because this is a 4-option multiple choice, we have to select one answer. But you're looking for the answer that best describes the first intervention you would do. So pause the video, do the work yourself, come back and I promise I will walk you through every answer choice and the rationale. Ready? Alright push pause, answer this question on your own.

03:56 Welcome back. I hope you did the work on your own. I know it's really tempting to want to fast forward and just listen to the answer choices but that's really not a good use of your time. You doing the work, figuring out why you picked what answer you did will help you take the benefit of the time you invest on this question and take it with you on the next exam or when you take your NCLEX. This is like having a personal tutor which you do have me right here to tell you how to look at your test taking strategies and make them better. So I got a 35-weeker, I'm listen to fetal heart tones. They suddenly have this change. What's my first intervention? Now don't make the mistake. Intervention could be either you assess something or you actually do something with the patient, either one. Sometimes people think an intervention means doing something and it can't be an assessment.

04:53 That's not true in NCLEX world. So that's my first F word. Well, that's my first intervention. So, number 1, immediately notify the rapid response team. Okay, so why would I do that? What does that answer choice really mean? Well, if I immediately notify the rapid response team, that means I think this patient is going to code or arrest or is in imminent danger. So, is that the case with this client? No. It's not. In fact, this would really freak everybody out to call the rapid response team because we recognize their testing. Do you recognize why this client is suddenly feeling hot, dizzy, and nauseous? Now, assist the client to lay on the left side? Did you leave that one in or out? I'm not really sure, like changing positions. Is that going to fix something? So if I was walking through, I can leave it in for now. Number 3, check the client's vital signs every 15 minutes. Now, wait a minute.

06:02 Does that address the problem? I have a patient right now, right here that feels hot, dizzy, and nauseous. Is checking their vital signs every 15 minutes going to be the first thing that I do? Nope, I can get rid of that one. Number 4, start an IV for administration of IV push medications. Wow, that seems kind of extreme. Doesn't it? Because hot, dizzy, and nauseous, what IV medication would we give? Unsure.

06:35 Okay, but let's look at 2 and 4. Now, what is particular about this client is I'm thinking they're pregnant, 35 weeks, they had a sudden change. Will putting them on their left side make a difference? The answer is yes. It will. So when I'm picking between 2 and 4, I want you to remember this; pregnant woman, left side, pregnant woman, left side, pregnant woman, left side, pregnant woman, left side, pregnant woman, you say it. Good. The reason you want to put a pregnant woman or assist them to lay on their left side is think about that giant big uterus. It's pressing down on those vessels that are bringing blood back to the heart. If I turn the client on their left side, we're going to relieve the pressure on those vessels that are bringing blood back to the heart. The reason they feel dizzy, the reason they feel hot, the reason they feel nauseous is because they're not getting adequate blood supply.

07:37 It's their body's way of telling "Hello, this is not going well for the mom or the baby." All you need to do first is to turn on the left side, get the uterus off that returning blood supply, and these symptoms should resolve. If they don't, then you take the next step. But that's not part of this question. This is just asking us "What do I do for the first intervention?" Now remember, our goal is always "What can we take from this particular question and use it on questions in the future?" Right? Otherwise, why would we study? This exact question won't be on the NCLEX but let me show you what you can use in the future. First of all, we talked about how to walk through the question. We know that for any assessment information, determine if it's normal or abnormal. Remember what's particular about this client.

08:30 35 weeks gestation and they have these sudden changes. It asked us for the first intervention. Always know that last sentence is ridiculously important in helping guide you on what you're looking for. Now, if you didn't know that moving a pregnant client on their left side will relieve these symptoms or should relieve these symptoms, men, add that to your notebook. Just write yourself a note and remember those 2 questions we always ask, "Why would a nurse need to know this? and "How would it keep a patient safe?" Well, why do you need to know that turning a client on their left side is helpful for pregnant women? Because you know the path though. You know if I can turn them over and get that big oh uterus off that returning blood supply, they're likely going to feel better. So you write down in your notebook whatever you need to remember, don't let this type of question catch you again. Now if a client who's pregnant has this suddenly sign, then we know this will likely fix it. So that's why I don’t need to call the rapid response team because they're going to run in and go "Whoah, okay let's all move around our left side." Right? That's not going to be the first thing you would do. Checking vital signs every 15 minutes. Oh yeah, I'd be doing that, but if I never move the client to their left side that's not going to be any good. I haven't addressed the problem. Start an IV for administration of IV push medications, way over the top.

10:02 Right? They don't need those medications. We think that if we start first with just moving them, the client should be fine. So, what do you put in your notebook? What have you written down? Because that's the notebook I will encourage you to keep reviewing and ask yourself "Why would a nurse need to know this?" "How would I use this information to keep a patient safe?" So let's do that one more time. Why would I need to know this? Well, I need to know the reason that this patient is feeling this way is that uterus is compromising the blood supply.

10:36 How would I keep a patient safe? Well, no one wants to feel dizzy, hot, and nauseous.

10:41 So, how I keep them safe is I would just turn them on their left side. So put those notes in your notebook, don't get caught by this one again. And if you got it right, celebrate, take a victory lab because that's pretty cool that you got it right.

10:57 Make sure there isn't anything else from answers 1, 3, and 4 that we talked about that you want to put down in your notebook that you can also review at a later time.