Nurses thinking multiple choice?

KRVRN, BSN, RN · Dec 3, 2002

With as much emphasis as they put on PAIN control in nursing school... never get sucked into answering one of those "what would you do first" questions by giving pain meds if there is ANYTHING at all airway-related. Pain comes after the ABC's.

purplemania, BSN, RN · Dec 3, 2002

My experience with nursing tests is that they involve the nursing process (this sometimes is a hint on what to do first: assess) and Maslow's heirarchy (breathing is way up on the list of things that are important). And don't read into the questions. Just go with the info you have. You did great! Good luck.

llg, PhD, RN · Dec 3, 2002

Congratulations on your 86%, Mario. It sounds like you are on the right track with your studies.

The one suggestion I have for ALL students is to make sure you find out from your instructor what the rationale was for the correct answer on all the questions that you miss. Most test questions are constructed to test a specific scientific/theoretical principle or fact taught in the course. The correct answer best matches that principle or fact while the "distractors" play off the tendency most people have to base their actions on less scholarly mental processes.

By identifying the principles and facts that you failed to use -- and reviewing the faulty logic that you DID use -- you might learn more -- and improve your test-taking abilities.

Keep up the good work.

llg

mario_ragucci · Dec 3, 2002

I really appreciate the excellent advice and talk about ABC. I think just like everybody else.

Can you think of any example "trick" questions about ABC, like, where ABC is not the answer? Because ABC is most important, I want to see "bad logic" where ABC might not be the number one priority on a PT.

Does ventilator transcend ABC? Thank you al so much, especially to Peeps for mentioning the tube feeding aspect. If a PT has a PEG, then perestaltic aspect may receive more priority, depending on the PT. From now on, everything is reality actually takes place in the "textbook make-believe world" of Fundamentals of Nursing first.

Not to rest on my laurrels and remember to stay cloistered in my apartment with the books leading up to an all night vigil on Sunday before the mega-final

KRVRN, BSN, RN · Dec 3, 2002

I think...

I have a vague recollection from waaayyy back that if defibrillation is indicated, then that should/can occur before airway...

Heard that from an old coworker that was in an EMT course. He and most of his class all missed the test question about it and tried to argue it to no avail; the instructor was a paramedic and wouldn't budge.

Anyone? Anyone? That correct when outside the hospital? Defibrillation before airway? It almost seems that if defiibrillation is even available, then there is probably SOMEONE else there that can either intubate or give mouth-to-mouth... in which case you've still dealt with airway first.

Dr. Kate, BSN, RN · Dec 3, 2002

A couple of comments.

Airway/breathing always wins 1st. If there's no oxygen getting in the heart can beat on and on and it makes no difference, still dead. If you really, really know they need defibrillation, and are sure without checking the airway is okay, then you defibrillate first (Pt on vent getting their volumes, monitor attached and working correctly shows V-fib--go for it.) Outside the hospital, it takes time to get an ACID, and someone should have already checked ABCs before it gets there.

Beware of feeding tubes, pegs and the airway. Just because there's a tube does not mean that the airway is safe from stomach contents.

As one of our CVICU nurses says of the days when he was a new grad and there were whispers about his being a hotshot paramedic: I told them I was a good paramedic but that was outside of the hospital, here I'm a not a paramedic but a new grad nurse, there's a big difference and I'm here to learn.

And Mario, I've got to tell you, I really enjoy your enthusiasm, frustrations, and insights into the process of becoming a nurse. Thanks for sharing them all with us.

Peeps Mcarthur · Dec 3, 2002

Defib first would depend on the rythm wouldn't it?

If you're perfusing at all, I would think you would want to ventillate so you can have some gas exchange. Restoring rythm to an acidotic myocardium seems ineffective, unless you were at cardiac standstill.

Hypoxia may be the etiology of the rythm.

In cpr training you provide breaths before compressions.

Got me away from my cruel world for a little bit anyhoo.

hoolahan, ASN, RN · Dec 3, 2002

Defib first only if the rhythm is known. This is the reason why some states have put AED's automated ext defibs in malls, and to cops, so that you slap on the pads, it will diagnose for you if it is v-fib, then shock as needed. If no shock indicated, it will tell you "Start CPR"

I can't think of one time when airway would not come first Mario, except as above, and you need special training to use this device, and this is not a part of nursing curriculum, so forget it. Usually EKG interpretation and critical care situations are not either, usually.

With a ventilator, there is an artificial airway, and yes, if that airway is obstructed by kinking, secretions, etc...it is still a priority.

Good suggestions to use nursing process assess, diagnose, implement, eval, and Maslow's as a rule.

Like that K question theory, how true.

nurseT · Dec 3, 2002

Mario, good job. But listen... don't get caught up in percentages on grades. Pay more attention to the points available in the class and do a little math. Decide how many points you need to get an A and try hard. An 86% to you may equal too little points to win. I made that mistake my first quarter, and barely got a C in pharm. Had to take it again, I had no clue. Also, Purdue requires 92 points to get an A, after I got it figured out, I seldom got an A. I always got 90 or 91 points. Sheese! Good Luck, NRSG is tough!

suni, BSN, RN · Dec 3, 2002

i had a terrible time with test and someone recommended a book called test taking tips for nurses. helped me immensely i have since passed this book on to people taking boards and they loved it, one of the first things they say is always remeber vs come first with any problem, i automatically did vs all the time and just thought of it as a no brainer answer, also if the answer is all of the above 80 percent of the time thats what they are going for. good luck with all your test we sure need new nurses.

CJ · Dec 4, 2002

I'm not a Nurse and I don't play one on Television.

What it is that I am doing is reading this thread on my Nurse wife's computer.

I can't discuss nursing question content, but being a long time teacher that took my first multiple choice exam about 53 years ago, I suspect I know a little about them.

It is extremely difficult to write a valid multiple-choice question. Every writer needs an editor. All test items must be validated.

How many nursing schools/instructors know this? I would bet very few.

Of course, test items that were not covered in the assigned text or in class are not only invalid but also downright unfair. My wife attended a *very* prestigious University school of nursing. She brought home her recall of a number of questions that she just didn't know the answer to. I would sometimes help her find them in the text or her notes. It amazed me how many were invalid. Some of them were taken from the teacher's life experiences and were just flat wrong.

It is very difficult to write an objective test item. Some would say impossible. One answer on one of my wife's finals was: Acne can be controlled by vigorous skin cleaning with soap and water. The teacher that wrote that had a bias that went all the way back to her adolescence. The fact that it was clearly contradicted by the text made no difference. If you answered otherwise, it was counted wrong. I suspect this long time "teacher" had not read the text for the last several editions.

kmchugh · Dec 4, 2002

Mario

It's Wednesday, and I kind of hope you read this before attending the test review. I agree with your answer, and here is my rationale:

The question, as you presented it, did not indicate that the patient was currently swallowing anything, or having any difficulty breathing. So, in any event, as long as conditions remain as they are in the question, the patient is in no danger from dysphagia. If someone hands that patient a glass of water, the whole equation changes, but for now, the patient is safe. Dysphagia only equates to an airway problem if the patient is being given liquids (or food, in some severe cases).

We are all taught the ABC's of treating patients, and they are a good place to begin. However, in determining PRIORITY of treatment, a real, current, life threatening, problem always takes precedence over a problem that may crop up later. Make no mistake, a bowel obstruction is life threatening.

With no further changes in the conditions of the test question, a bowel obstruction is at least an urgent situation. It can rapidly become an emergent situation, requiring emergency surgery, RIGHT NOW, to correct, with no changes in the conditions of the test question. Sometimes, a bowel obstruction will clear up with tincture of time, and decompression of the bowel (i.e.. NG tube). Sometimes, it will not, and will require surgery to correct. In any event, the first order of business for a patient with a suspected bowel obstruction is to make the patient completely NPO. Put nothing else into the bowel to compound the problem. Hence, the first treatment of a bowel obstruction eliminates the part of the aspiration worries for a dysphagic patient. Read on, though, because it does not eliminate the greatest danger.

Now, to take it one step further (I love this, because it demonstrates how neatly our organ systems are interconnected and interdependent). What is one of the principal symptoms of bowel obstruction? Violent, persistant emesis. What is the absolute worst thing that can happen to a patient's lungs, short of a 12 gauge shotgun at close range? Aspiration of stomach contents. The pH of stomach content is so low, it causes immediate, life threatening damage to the lungs. In most cases, these patients, if they recover, spend a minimum of three weeks on the ventilator in the ICU. The patient is already dysphagic. There is no intervention, nursing or otherwise, you can take to change that, or to prevent aspiration of stomach contents when (not if) the patient vomits. So, treatment of the bowel obstruction is even more urgent in a dysphagic patient. Make sense? I know surgeons who would be much more hair trigger to take the dysphagic patient with a bowel obstruction to the OR to prevent the aspiration problems I mentioned above.

I'd also ask to see the reference the instructor used to determine that dysphagia is the more immediate problem.

Kevin McHugh, CRNA