NCLEX Strategies: Recognizing Expected Outcomes

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You spent much of your time in 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 nursing school faculty wrote focused on what was wrong with clients and their care. In order to prove minimum competence, the beginning practitioner 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-RN® 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. Here is the path to finding the correct answer for Expected Outcomes questions:


 

Practice Question 1


Look at the following question.

The physician orders an arterial blood gas (ABG) for a client receiving oxygen at 6 L/min. Results show pH 7.37, HCO3 26 mm Hg, pCO2 42 mm Hg, pO2 90 mm Hg. Which of the following should the nurse do first? 

  1. Increase the rate of oxygen flow the client is receiving.
  2. Elevate the head of the bed.
  3. Document the results in the chart.
  4. Instruct the client to cough and deep-breathe.

If this question were included on one of your medical/surgical tests, you would assume that a problem was being described. So you would choose an answer choice that involves “fixing” the problem. Let’s look at this question.
The Reworded Question: What should you do with a client with these ABGs?
Step 1. Recognize normal. Interpret the ABGs. All are within normal limits.
Step 2. Decide how you should use this information. Because they 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 ABGs?

Answer and Explanation


(1)  “Increase the rate of oxygen flow the client is receiving.” This is unnecessary because his O2 is within normal limits. Eliminate.
(2)  “Elevate the head of the bed.” This is unnecessary because the ABGs are within normal limits. Eliminate.
(3)  “Document the results in the chart.” This action should be done because the ABGs are normal.
(4)  “Instruct the client to cough and deep-breathe.” This is usually recommended in a situation in which there is some limitation of respiratory function, due to immobility or post-operative conditions, for example. The only information you are given in this question is the client’s ABGs, which are within normal limits. Although this could be done, you are given no indication that it is necessary. Eliminate.
The correct answer is (3). The ABGs are within normal limits. Some students select answer choice (2) 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.

Practice Question 2


A client is brought to the emergency room complaining of pressure in her chest. Her blood pressure is 150/90, pulse 88, respirations 20. The nurse administers nitroglycerin 0.4 mg sublingually as ordered. After five minutes her blood pressure is 100/60, pulse 96, respirations 20. Which of the following should the nurse do next?

  1. Notify the physician that the client has become hypotensive, and obtain an order to administer IV fluids.
  2. Place the client in semi-Fowler’s position, and administer O2 at 4 L.
  3. Administer a second dose of nitroglycerin.
  4. Document the results, 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. A decreased blood pressure, increased pulse, and stable respirations after administration of a potent vasodilator are 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?”

Answer and Explanation


(1)  “Notify the physician that the client has become hypotensive and obtain an order to administer IV fluids.” The blood pressure has decreased due to vasodilatation. Decreased blood pressure is expected. Eliminate.
(2)  “Place the client in semi-Fowler’s position and administer O2 at 4 L.” Respirations are stable and there is no indication of respiratory distress. Eliminate.
(3)  “Administer a second dose of nitroglycerin.” The nurse should assess the client for chest pain first, and administer a second dose of the medication only if the client continues to complain of chest pain. Eliminate.
(4)  “Document the results and continue to monitor the client.” This is the correct choice because you recognized 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.
 
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