Next Generation NCLEX - What Is a Bow Tie Question?

3rd in a series: the Next Gen NCLEX will roll out in the Spring of 2023. Read on for a sample “bow tie” question – one of the new “stand alone” question formats that tests clinical judgment.

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Next Generation NCLEX - What Is a Bow Tie Question?

I hope you've read my article about the Next Gen NCLEX, Next Generation NCLEX - Are You Ready?, which debuts in the Spring of 2023. One new component includes stand-alone items. Two stand-alone items will be offered: the bow-tie and the trend. Candidates who continue beyond the minimum length exam may receive as much as 10 percent of these item types on the rest of their exam.

Bow Tie Question:

The Bow-Tie item incorporates all six functions of clinical judgment in one item (recognizing cues, analyzing cues, generating solutions, prioritizing hypotheses, taking action, and evaluating outcomes). After being presented with a scenario, the candidate will

  1. Decide if findings are normal or abnormal (recognizing cues),
  2. Identify the possible complications or medical conditions the client may be experiencing (analyzing cues)
  3. Identify potential solutions to address the client's needs and issues (generating solutions)
  4. Determine the most likely cause of the client's issues (prioritizing hypotheses)
  5. Select appropriate actions to take (taking action)
  6. Choose what parameters to monitor once interventions have been implemented (evaluating outcomes)

Practice Scenario

  • 70 yo Asian American female, Weight: 160lbs; Height 5'
  • Upon admission, family reported the client had been nauseated with vomiting for 4 days. "Her fever has been over 102°F for the last few days and she won't eat or drink or take her medications.”
  • Client is confused AOx2, not oriented to time
  • Lab values: serum glucose of 585; BNP 32; Na+ 148; K+ 4.7; Serum osmolality 300 mOsm/kg, Anion Gap 15 mEq/L, Serum ketones 3.1 mmol/L
  • Vital signs: BP 171/97, HR107; RR 26; Temp 102.2°F, SPO2 95% on RA
  • She has poor skin turgor
  • Treatments: started on an insulin drip that discontinued 4 hours ago and started on regular NPH insulin
  • PMH: smoker – ½ ppd 40+ years; DM II; CAD; HTN; Hypercholesterolemia; Neuropathy bilat LE.

Home Medications

  • Losartan/HCTZ 100mg/12.5mg PO daily
  • Fenofibrate 160 mg PO daily
  • Metformin 500 mg PO 2x daily

How to answer:

You can only choose TWO actions to take, ONE potential condition and TWO parameters to monitor. Think of each component as a multiple choice – there may be more than one right answer, but you must prioritize to decide what is MOST important.

bowtiequestion.jpg.a3ae660f1ee88536d5435ac51d9b4ed4.jpg

Think you have it figured out?

Potential Condition:

This patient has Diabetic Ketoacidosis (DKA) which develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in your body. HHNS is another possibility, but the blood glucose and serum osmolality need to be higher for the client to qualify for HHNS. She has a history of HTN and her current BP is elevated, but that isn't the primary, driving factor for her current visit to the ER. In addition, for hypertension to be the issue, you would need more than one isolated BP. Remember, you can only choose ONE – pick the one that brought her to the ER. She might have influenza, but the only clue to infection is an elevated temperature. Infection often causes DKA, but you don't have enough information to choose this option.

Actions to take

(I like to ask myself – "If I didn't do this action, would it kill the patient?" If the answer is yes, then I pick that one)

Administer Potassium as ordered. In DKA, potassium may be lost from the body in large quantities, though initial serum potassium can appear normal or elevated because of the extracellular migration of potassium in response to acidosis. Potassium levels generally fall during treatment as insulin therapy drives potassium into cells. If serum potassium is not monitored and replaced as needed, life-threatening hypokalemia may develop.

Assess the feet for ulcers or infected toenails. DKA is often caused by an infection and this patient has peripheral neuropathy. It is possible she has an undetected infection. You would also anticipate a blood draw for culture and sensitivity and a urinalysis.

Fluids would include 09%NS, NOT Dextrose! Adding more sugar will make the DKA worse.

Administering PO Tylenol won't be effective until the N/V is controlled. IV medications will be needed. Due to the threat of infection, using aseptic technique for IV insertion and medication administration is critical so using clean technique might actually "kill the patient". Though it is important to teach about dosing of all medications, it is likely that this patient has been unable to take her medications due to the N/V. This is not your primary focus.

Parameters to monitor

(Again, use the "Which one will kill the patient?” technique.)

You will want to monitor Intake and Output due to the dehydration she is experiencing (did you notice her serum osmolality, the poor skin turgor, the fever and change in mentation? All of those are symptoms of dehydration – which is likely with 4 days of N/V – this is something you should have anticipated finding when using your critical thinking skills). You would also anticipate checking her blood glucose level, typically every 1-2 hours for a patient on IV insulin therapy. Not assessing blood glucose levels could "kill this patient".

Though orthostatic BP is important to assess initially, there is no indication that low BP is an issue. This is important, but not as important as monitoring I&O and Blood sugar. Neurological assessments would occur every 2-4 hours at first until return to baseline is achieved. There is nothing in the scenario to indicate an infection, so assessing for an allergic reaction to antibiotics is not important at this time, though it may be if infection is discovered and treated – don't read into the question. Many patients in the Emergency room get an EKG, but this patient is not demonstrating any signs or symptoms of cardiac issues. Her BNP is WNL.

Next month look for "The Trend"

References

ATI testing resources for NextGen NCLEX 
NCSBON info about NextGen NLEX

Getting Ready for the NextGen NCLEX

Diabetic Ketoacidosis

Merck Manual

American Diabetes Association 

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SafetyNurse1968

About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety.

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Specializes in oncology.
On 11/3/2021 at 12:47 PM, SafetyNurse1968 said:

Assess the feet for ulcers or infected toenails. DKA is often caused by an infection and this patient has peripheral neuropathy. It is possible she has an undetected infection. You would also anticipate a blood draw for culture and sensitivity and a urinalysis.

On 11/3/2021 at 12:47 PM, SafetyNurse1968 said:

There is nothing in the scenario to indicate an infection, so assessing for an allergic reaction to antibiotics is not important at this time, though it may be if infection is discovered and treated – don’t read into the question.

Not reading into the question....reading into your replies. Please explain why one rationale would say the opposite of another rationale.

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Specializes in Education, Informatics, Patient Safety.
On 11/10/2021 at 11:12 AM, londonflo said:

Not reading into the question....reading into your replies. Please explain why one rationale would say the opposite of another rationale.

Thank you for bringing this up. I definitely should revise it-she has a fever so that is one sign infection so that is a mistake on my part -I shouldn’t have said no signs of infection, however assessing for infection in the toes does not mean that she has one. I definitely could’ve written my rationale better. I hope that helps. I’d love to see what you could come up with. It’s always fun to collaborate. Writing test questions and rationales is difficult, and this is my first attempt at a bowtie.

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Specializes in oncology.

Are these questions being designed for entry-level RN positions? The complexity of the problems in this patient seem to show she would be destined to an IMC/ICU unit.

What is the real point for listing these possible ACTIONS TO TAKE?  the D5 fluid, Teaching about meds, Tylenol (po). Administering K+ as administered, "clean IV insertion", would either require a MD order or are not a priority (except getting a Tylenol supp. to decrease her metabolic rate). The Assessment of feet is the only one that seems reasonable for a nurse and a nurse without a doctor's order.

Please do understand I am not against you;  and the NCSBON when proposing tougher, actually clinical situations. Somewhere they need to reclarify what the entry level nurse needs to know. They have  had that document for years but if the acuity of the test increases, they need to modify the document. Best wishes, I was in your position for many years ... it is a tough one

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Specializes in Education, Informatics, Patient Safety.
londonflo said:

Are these questions being designed for entry-level RN positions? The complexity of the problems in this patient seem to show she would be destined to an IMC/ICU unit.

What is the real point for listing these possible ACTIONS TO TAKE?  the D5 fluid, Teaching about meds, Tylenol (po). Administering K+ as administered, "clean IV insertion", would either require a MD order or are not a priority (except getting a Tylenol supp. to decrease her metabolic rate). The Assessment of feet is the only one that seems reasonable for a nurse and a nurse without a doctor's order.

Please do understand I am not against you;  and the NCSBON when proposing tougher, actually clinical situations. Somewhere they need to reclarify what the entry level nurse needs to know. They have  had that document for years but if the acuity of the test increases, they need to modify the document. Best wishes, I was in your position for many years,,,,it is a tough one

The NCSBON is phasing in the next GEN NCLEX in the Spring of 2023 for entry into practice. So this will be the test nursing students will take after they graduate from nursing school. I wrote an article about their reasoning, which has to do with identifying that 60% of new nurses do not appear to have a good clinical judgment. Since this is already instituted, I'm trying to help new students pass. If you are concerned with the level of the questions you might consider contacting the NCSBON. As you can see from my references I got this information from their website. I hope that helps, I really appreciate you reading my article. The article was written for nursing students.

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Specializes in oncology.

Yes, after teaching nursing for over 40 years I can identify with how hard it is to write clear, discriminating questions that need the operation of critical thinking to answer! I applaud you taking on this task coming from the NCSBON. . I am glad there are a couple years  ahead to incorporate the new ways of testing into the nursing school curriculum so that the graduate applicants can get some experience with them.  

AS this has already been decided by the NCSBON all schools will have to go along with incorporating these questions whether they agree or not. 

Instead I wish that the CCNE would instead revise their criteria for accreditation....this is only my opinion. I have had extensive experience with ACEN accreditation visits (both new and continued accreditation and found them to be exceptionally  thorough.)  On the other hand, the CCNE seems determined to grant accreditation to any for-profit school that comes along. (My evaluation model was looking at the 3 components of : Input, throughput and output.) 

These thoughts are only my opinion.  Once again I am thrilled you are taking up this most difficult job! Best wishes.

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Specializes in Education, Informatics, Patient Safety.
londonflo said:

Yes, after teaching nursing for over 40 years I can identify with how hard it is to write clear, discriminating questions that need the operation of critical thinking to answer! I applaud you taking on this task coming from the NCSBON. . I am glad there are a couple years  ahead to incorporate the new ways of testing into the nursing school curriculum so that the graduate applicants can get some experience with them.  

AS this has already been decided by the NCSBON all schools will have to go along with incorporating these questions whether they agree or not. 

Instead I wish that the CCNE would instead revise their criteria for accreditation....this is only my opinion. I have had extensive experience with ACEN accreditation visits (both new and continued accreditation and found them to be exceptionally  thorough.)  On the other hand, the CCNE seems determined to grant accreditation to any for-profit school that comes along. (My evaluation model was looking at the 3 components of : Input, throughput and output.) 

These thoughts are only my opinion.  Once again I am thrilled you are taking up this most difficult job! Best wishes.

So nice to get some positive feedback -thank you!

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This was a very good read and insightful. However, that scenario and bow tie question seems a little complex and advanced for the nursing students that will be taking the new NCLEX. I hope educators are preparing right now to implement the necessary changes so that their students can be successful when they take their state board exams 

PS. I absolutely love your case studies and clinical scenarios oh, it makes me critically think and dig deep in my nursing knowledge. I look forward to the trend example next month

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Specializes in N/A.

Are all candidates required to take the Next Gen NCLEX exam? I.e. people who graduated in the years before this becomes live?

 

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Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.

While it may be true that a given part of the medical plan of care may require a qualified prescriber (not "a doctor's order" -- we are not in the dang army and there are other prescribers at work in most settings), nurses ARE required to recognize when something would be harmful or priority when implementing nursing's parts of the medical plan of care. So yes, knowing about prioritizing aspects of medical care for DKA, potassium, dehydration, and the like are something the nurse should know.

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