Strategies on How to Answer the Next Generation NCLEX (NGN) Type Questions

Okay, so good evening, everyone. Welcome to another episode of Connetics college with IPass. So, those who are taking time to attend this lecture tonight, wherever you are, whether you are in the Philippines or anywhere outside the Philippines, so in the United States or anywhere, so, I'd like to thank you for taking time to attend this lecture with me. So, I believe that for 10 days from now, so, we will be having our full implementation of the next generation NCLEX So, tonight, we will be dealing with strategies to answer NGN type questions. So I intend to focus tonight more of standalone questions so that you We'll be able to be certain on how you go about dealing with different types of questions, rather than these case studies. Because as we all know, there will be like 25% new question types, that's going to be out this April one of 2023.

And part of it will be the case studies, which we examining, we'll be having at least or will be getting at least 2118 rather taking questions from this case studies on top of air there will be like, additional 21% new question, which will be dealing about these standalone restaurants. So definitely the bulk of the question for the NGN types will be basically focused on the standalone questions with the additional of what we call case studies. So as I've mentioned, I intend to discuss with you tonight the different item types and also with strategies to answer it. So without further ado, let me share you my screen. Okay, so, Miss, Miss Melanes screen share me, can you share my screen? Okay. So, okay, Miss Melanes, is it am I going to because later on, I'll be the screen. So, probably, the students perhaps will then write because of some technical issue with my connection right now. So, I wasn't able to upload my presentation today. So, Miss Melanes from Connetics nurses recruiting agency is gonna share my screen on my behalf. So, so, later on during integration of some incidental learning or information please take time to write their on your piece of paper, so, that you will be able to get the gist of the questions or the information. So, basically, with the next generation NCLEX as I've mentioned, coming April one of 2023 there will be a test competency this is going to be a new format of NCLEX.

So, it measures the competency of the nursing applicants and one thing is certain the entire computer itself is computer adaptive testing still, so meaning to say questions are geared towards to the level of the persons completing the examinations. So, questions are reflective, these are reflective of the nursing practice today and this will test your clinical judgment scale. So, once we say of the clinical judgment scale, we define that as a result of the critical thinking and the critical decision making and for able to safely render quality nursing care to the patient, it requires the nurse to employ this nursing process basically this clinical judgment models the nursing process, they intend only to categorize this into six functions in order for you to become very familiar on what are the steps. So, these steps comprises from your recognized cues, analyze cues, prioritize hypothesis, generate solutions, Shawn's and evaluate outcomes. So, as I've mentioned, this is basically a nursing process. So, in the nursing process, we intend to analyze we intend to assess as a first step to analyze we plan we implement and we evaluate. So in this session, we will be dealing on some specific item format that is focused on recognizing the cues and later on, I'll be giving you some important strategies on how are we going to attack this question, the NCLEX Okay, so next. Okay, so, let's now move on to recognize skills. So let me let me go ahead. start my presentation. So that is first is the first step is to recognizing cues. So in recognizing us remember nurses, you have to ask yourself what matters most with this. So you're going to definitely use this information that is going to be presenting you in the examiner in the in the tabs that you will be getting during your APA examination. So here I intend to give you a sample about the drop down close. So, adapt don't close is a new test format, which aims the nurse to select Options from the given drop down. So, as you can see with this this example, so, there will be a scenario there will be a tab here for example, the nurses notes and these are the questions and the following are your tasks. So, your task is to complete this job down close. So, let me go ahead read the scenario. So, what is this drop down close or the scenario all about? So, number one, so, the nurse is reviewing the nurses notes for an 84 year old client admitted to a skilled nursing facility. So, during the examination you will be presented with different tabs. So, the technique here is to take time to read and open all the tabs that has been provided for you because the information's are given to you. So, with these Our task is to recognize skills, we need to find out what are the most important cues that matters, because this means they this may give us opportunity to identify whether the concern of the patient is immediate or not something that the nurse has to to intervene immediately or to take action immediately. So it goes the nurses nose goes like this in 2100. The client transferred from the community hospital following a ride total knee amputation for physical therapy or occupational therapy. Some states that father has been confused a time since surgery but has no previous diagnosis of dementia. So need supervision when transferring from bed to chair incontinent of urine at times able to feed itself and needs assistance with dating the patient had episode of failure yesterday. So, a patient had failed yesterday while in bathroom while unattended with Walker. So, vital signs are the following temperature of 98 degrees Fahrenheit or 36.7 degrees Celsius use heart rate of 88 pulse rate of 18 beats per minute the BP of 100 to over 64 millimeters mercury upon in the SIP measurement in setting. So the right knee incision is dry and intact with steric strips. Currently patient is alert and oriented. The nurse has took this assessment or three times. So history with hypertension transient ischemic attack or TIA The patient also had history of stress incontinence and osteo arthritis. So our task here is to recognize the queue so based on this information or nurses notes question is based on the clients finding, okay, Complete the following sentence by choosing from the list of options provided. So, these are the drop down the drop down options already. So, the nurse recognize that the relevant client findings that are of immediate concern to the nurse are so in this example, your task is to immediate concerns from this option for option one the drop down should be our 18 beats per minute the Convert to over 64 millimeters mercury upon sitting and heart rate heart rate of 88 beats per minute. So what do you think is the answer here? Actually, I cannot I cannot see any let me check my phone right now. So that I will be able to check whether Okay, whether there are participants already.

Okay, so let me check. Okay, so here Okay, so any guests with the Option One immediate so the concern here, the nurse recognizes that relevant client findings are of immediate concern. So I intend here to highlight red the immediate concern to the nurse based on the nurses notes can anyone or Can somebody can somebody answer option one. Okay. Any guess? Okay, and it gets guys. Okay. So let's answer here BP of 100 to over 64 millimeters mercury upon setting. Okay, so number two. So what are the possible what is the possible answer for option two? So just you just have to click this and The options will drop down. So hence the word drop down close. So confused at times since surgery. So history of transient ischemic attack and admitted for PTE OET after taking after a total knee amputation, any answer? Any guest for option two. Okay, correct. I saw Miss Yolanda Valdosta and Shawn. So Miss Agel DiNardo mentioned about BP Correct. That is for option one. So this time for option two, any guess? Any guests from the from the participants? Okay, and it gets when the participants so this time? Okay, I'll be selecting here confused at times since surgery. Okay. So I intend to choose confuse a times since surgery. And number three. Okay. Any guess for number three? So options are fairly yesterday. alert and oriented times three and incontinent of urine. Okay, so correct. So correct answer there is confused at times. Correct. So, in option three, does anyone from the group? Does anyone? Okay, thank you so much. Miss Jen, the rule fell yesterday for option three. So let's answer again for option one. So we have we think of this immediate concern that the nurse has to react. Okay, so we selected for option one, BP 100 to over 64 millimeters for sitting and up to four confused a time since the surgery. And option three, the patient fell yesterday. So let's now go ahead with discussing the rationale. Okay. Okay, let's go ahead. Can you move through the slides, ma'am. Okay, so what is now rush, the rationality for this. Remember, guys, remember, guys, the client is an older adult. So the client is an older adult who had a surgery several days ago before admitted to the skilled nursing facility. So analyzing the following cues. So we, we already established that the vital signs are within normal limit, except for one blood pressure why this blood pressure is seems to be low, it's a not within the lower normal limit, and it's very low 102 systolic and 64 millimeters mercury as the diastolic. So, it is also important guys, it is basically expected for a normal adult to have a slight decrease in systolic and diastolic pressure when we change our when we move or change from sitting or lying position. But remember with this scenario, the client is adult, so the client is elderly client. So, so, it is expected that the patient based on that cue the patient is suffering probably from orthostatic hypotension. So, what is this all to study hypertension then so, so, when there is a significant decrease in systolic, so, I will I will never write here I cannot write here. So, kindly write their the answer in your own in piece of paper that you have right now. So just to facilitate the learning process, so, what is this orthostatic hyper hypotension again, so, when the patient there is a crease in systolic pressure for at least 20 So right here 20 millimeters mercury or diastolic of 10 millimeters mercury within three minutes of moving okay. So, magic number is 20 for your systolic and 10 for your diastolic this is what we call orthostatic hypotension. So, what is now the importance or significance of understanding this orthostatic hypotension in terms of my patient based on his skills. So, remember that this auto static hypotension may contribute to what we call fall incident okay. So fall incident and also remember that the RN heart rate or seems to be the normal limit. So except for the BP so it is expected that the patient is Having or experiencing an orthostatic hypotension. And with that in mind, we can say that the patient is predisposed to having what we call fall incident. Okay, so number two based on that option, so let's discuss what is this confusion. So, remember in confusion, it is actually an immediate concern. Remember confusion is an immediate concern, because client may tend to get up with bed without supervision. So the client is confused meeting may get may get up and visit without supervision and experience an incident of fall. And remember, guys, when the patient had this fall, this is actually a sentinel event. So the quality the gravity of fall depends upon how, how I'm devastated the scenario was, so for example, the nurse forgets to increase the side rails or raise the side rails and the nurse forget, for example, to keep the head of bed within the possible low waist height level. So let's say when the patient fell down, and the head first fell on the ground. So possibly, because of this scenario, the patient might have another episode of stroke or what they call bleeding. So as I've mentioned, again, confusion is an immediate concern, because the client may give up on that without supervision and experience fall, okay. So, another idea that the patient has a pretty useful history. So, the patient has a previous fall history and this is a as a major, so remember this a major risk factor for additional fall. So we have Rehab we have to remember that any history of TI a or what we call transient ischemic attack is not actually an immediate concern. Okay, remember, history of transient ischemic attack is not an immediate concern, but for this reason, okay. For this reason, the nurse okay. So for this reason, the nurse has to has to the nurse has to like a monitor for possible indications of BIA, okay, the nurse has to monitor person possible instead incidence of TIA or stroke that is needed while the patient is in your skilled nursing facility. So okay, so with that in mind, so question number one for the drop down close, we answered the BP is very important or to static hypertension, the patient is confused. So the patient is predisposed to having a fall. And also the previous fall history may somehow give you opportunity to identify that your patient is actually Megan to another episode of fall. So very important that even if the patient had history of transient ischemic attack, the nurse should anticipate for possible signs and symptoms of reactivation of the DA or what we call the stroke event. Okay, so.

Okay, so Ma'am, can you move? Okay, so for the test taking tips here, guys, remember, so for the drop down close, so it is used to measure your multiple cognitive skills needed to make a clinical judgment. So your drop down close, wherever you are, assess whether you are able to identify the relevant client findings that are of immediate concern to the nurse. So what you're going to do is, is to for you to analyze this to recognize make use of this cues that is being provided to you. You can you can list down and organize these steps or these cues for you and somehow identify whether it is a immediate concern or not a concern. So with this again, let's have a recap. So an AR of 18 beats per minute. Do you think it's a concern or not? Do you think? Okay, or is a concern or not? Definitely it's not a concern for BP 100 to over 64 in sitting measurement. This is a immediate concern, okay, are heartrate 88 It's within normal limits. So meaning to say it's not a concern. So confused a time since surgery. As we have mentioned as we have discussed, it is an immediate concern. So transient history of transient ischemic attack, it's not a concern, but rather the nurse has to monitor for another episode of reactivation of PA or stroke as mentioned. So next admitted to BP occupational therapy after a, a total knee amputation. They think it's an immediate concern or not a concern this time. So it's not a concern as well. The patient fell yesterday, it's actually a immediate concern. alert and oriented is not a concern. So you put here an X, okay. incontinent of urine, they think incontinent of urine is an immediate concern or not a concern. Good, okay. Correct. It's not a concern. So remember that urinary incontinence is also a risk factor for fall. Remember, that is also a risk factor for fall, but it's not an unimportant as for history. So, based on the information is also provided the patient is alert and oriented three times. So even if the patient is incontinent of urine, the patient cannot can obey commands. So the patient can contain obey or can follow the instruction given by the nurse because he is alert and oriented. Therefore, incontinence of urine is not a concern at this time. Okay. So now let's move on to number two question. So number two is all about analyzing use. Okay, can we can we now move on ma'am? Melanes? Okay. So in analyze cues, nurses, you have to ask yourself, What does it mean from the cues that was presented to me, what does it mean? So, how should I utilize these skills in order for me to effectively manage my patient? So with this example, with this level, I intend to give you an example about the matrix, multiple response question. Okay. So, what is this multiple matrix response question later on, we will be discussing that. So what is the scenario, so a 96 year old client with COPD, was admitted to the medical surgical unit from the emergency department with complaints of increased shortness of breath, cough, pipe palpitation, and more mucus production than normal. So you will be again presented with several tabs. Remember, the key in order for you to understand the whole scenario is please take time to open all the tabs Okay, remember all the tabs there information's for you to be able to analyze for you to be able to understand the cues, the condition of the patient. So Please be certain to open all the tabs that has been provided to you in order for you to understand the condition or the client's condition. So let's now go ahead, read the health history. So the health history of the patient, the patient is unknown diabetes, and the patient is COPD patients. Okay, chronic obstructive pulmonary disease patient. So the patient is taking these medications theophylline short and long acting beta adrenergic agonists. So the patient also taking high dose inhaled corticosteroid prednisone into the angler gene and insulin as part as part of his treatment medication. So let's go ahead read the nurses notes. In 1400. The patient color is pale copying and expectorated in yellow colored spew tone and complaining of chest tightness, lung sounds reveal wheezing and diminish breath sounds bilaterally. So the point of care resolved the blood glucose is 295 milligrams per deciliter or 16.8 millimoles per liter. The vital signs are the following. So temperature 101.8 degrees Fahrenheit or it's obvious that the patient is having a fever of 38.8 degrees centigrade with an article heart rate of 120 beats per minute and regular so blood pressure is normal. So 128 over 80 millimeters per mercury and RR or 20 beats per minute. It seems to be normal. However, the oxygen saturation is seems at 88% on room air. So oxygen saturation is 88% on room air. Okay, can we now move on to the next slide please? Ma'am? Okay, so the Question here is for each assessment finding below. Click this specify if the finding is consistent with COPD exacerbation, pneumonia or adverse effect medications. So each assessment finding may support one or more condition. Okay, so in this time span this time you can select any one you can select two, or even you can select three as long as the condition or the signs and symptoms is applicable with the given condition. So let's go ahead and identify whether the assessment finding increased shortness of breath. Okay, is consistent with COPD exacerbation. They think increased shortness of breath is consistent to COPD exacerbation, yes or no? Do you think? Okay, do you think that COPD exacerbation is consistent with increased shortness of breath? Okay, Miss. Thank you Miss Jen. The room Yes. In team is the root cause and Miss Ramanika? Yes, yes. Correct. So put an X here. We think pneumonia waiting in case of pneumonia. Is there also a increase shortness of breath in pneumonia? Yes or no? They think pneumonia. There is also an increased shortness of breath. Correct. So put an X here as well. You think increased shortness of breath is the adverse effects of that medication. They think for me I find it No. So let's move on with cough incorporating COPD exacerbation on the patient will present with COPD yes or no? I think it's yes. elsewhere as well. And pneumonia. They think cough. Okay. In pneumonia. Is there a copy pneumonia? Yes or no? Okay, is there a calf pneumonia? Yes or no? Guys? Yes. Let me repeat my question. Is there a cop in COPD exacerbation? Yes or no? Yes. Okay. For COPD, correct. So let's now move on to increase mucus production. We think increased mucus production. Okay, can be seen to patient with COPD exacerbation? Yes or no? I think Yes. Correct. Pneumonia. Okay. Can that be seen as well? Correct. Thank you so much. Miss Ramanika and Miss Katie. Correct. What about for how heart palpitation? They think in COPD and pneumonia? Is there a heart palpitation? There? Yes or no? Is that consistent with that? I think no. Like my palpitation cannot be seen in COPD or pneumonia. But that is an adverse reaction of medication. So I'll put an x here. And blood glucose of 295 milligrams per deciliter. Do you think a patient with COPD can present a high blood glucose? Yes or no?

Do you think a patient with COPD exacerbation? Can a patient increase his or her blood glucose 295. Guys, do you think yes or no? Okay, the answer there is yes. Actually, later on we will rationalize why saving COPD there is an increased blood glucose level. They think pneumonia. Is there. Is there a increase blood glucose in pneumonia? Yes, definitely in adverse effects of medication Do you think? Do you think there is an adverse effect? Rash remember, based on the presentation of the patient, remember that your patient is taking castigo steroid, your patient is also taking prednisone stone your patient is also taking insulin bludgeon and insulin ask us why because the patient is a known diet. Local can be seen to all second circumstances COPD, pneumonia and adverse effects of medication. Yes, definitely because of the steroids. Okay, let's now move on with fever. They think MP COPD exacerbation there is a fever yes or no? I think no in pneumonia. So we believe that pneumonia is a infection definitely sign of infection is fever. Okay, adverse effects of medication Do you think no, there is no such thing as fever in adverse effects of medication SPO to 80% on room air, do you think in COPD exacerbation? Okay, can that be seen? Yes. In pneumonia can also be seen In pneumonia SPO 280 8% on room air, do you think it can be seen as well with pneumonia? Definitely because what happens during pneumonia there is a poor oxygen perfusion. So if there is there is a poor oxygen attribution. So meaning to say, okay, that the oxygen saturation SPO two is definitely decrease. So let's now go ahead and discuss the rationale layer. Okay, so remember guys, okay, remember, so there are usual manifestations of COPD exacerbations. So what are the manifestations of COPD exacerbation? One, the patient might consider that they have an increased coughing. So here might be increased coughing, the patient might presented with squeezing, the patient has presented with more shortness of breath, okay, more shortness of breath than usual. Okay. So are there signs and symptoms, other manifestations of COPD exacerbations? Number one, the caller make changes. So, what is the problem with COPD patients they have problems for so long with oxygenation. So probably they will be presented with they are they will be presented as pale the color is pale. Okay. So thickness as well. Or also the amount of mucus so unusual amount of new course. Okay, so remember as well in in some COPD, okay in some COPD patient, the SPO to have 88% Okay, can be normal, or it can be indication of can be indicated to a COPD exacerbation. What about for pneumonia? So remember in pneumonia, there is a fever. Okay, there is a fever, a cough. So Marian came cough and also mucus production, there is shortness of breath and the SVO two could be lower due to compromise. Okay, due to compromise respiratory status. As I've mentioned, the problem with pneumonia is poor perfusion. Okay. Okay, there is a mismatch with the perfusion of oxygen and carbon dioxide that leads to compromise, respiratory status. Okay. Another characteristic of pneumonia. In terms of pain, your patient your patient is experiencing sharp or stabbing pain, okay, so sharp or stabbing pain, which is also a characteristic of pneumonia. So what about for this glucose level? Okay, so remember guys, remember your patient has infection as evidenced by temperature of 38.8 degrees centigrade. Remember guys during infection, remember, infection or your infection increases the glucose level. Okay, so the answer here, your glucose level increases in the presence of infection. Okay, judo, okay, Judo another unknown area. So due to the body's response, okay, due to the body's response to amount of certain hormones, so response of the bodies in terms of the certain hormones, so what are these hormones that are evident during infection? That is significantly increase? Okay, during infection, one is your cortisol, and the other one is adrenaline. So cortisone and adrenaline, okay, leads to body's increased production of glucose.

And, from the history itself, we already established that your patient is taking prednisone alone or impossible steroid, this can also increase the blood glucose by making the liver resistant to the insulin. So remember this rationale there? Okay, what about for these theophylline What is this theophylline the ophylline is a bronchodilator. So what matters most is when our patient takes this the opaline the nurse should be able to to anticipate that in Theopolis there is such thing as signs and symptoms of Dr. Palin toxicity Tea. So when the patient is a long term diapason user, so the nurse should be able to anticipate the signs and symptoms of Theopolis toxicity. So what are the examples of signs and symptoms of the appearance toxicity? And this anyone from the group can share their knowledge about the signs and symptoms of the authentic toxicity. Number one that is your nausea. Okay, nausea, vomiting, abdominal pain. We also have taki cardio. We have the muscle tremor in your heart palpitations. So remember that heart palpitations is also a sign of toxicity. Okay, let me repeat again, nausea, vomiting, okay, abdominal pain, backache, cardio, muscle trim more in your heart palpitations are also signs of toxicity. Okay, signs of your toxicity. So okay, so for the next slide, we also have this test taking tips. So what are the state test taking step as I've mentioned a while ago, so increased shortness of breath. This is related to added stress on the respiratory system. So in pneumonia, it is also same. So adverse effects of increased shortness of breath is not specifically related for the cop that is related to the chronic manifestations of COPD, that has been worsen, especially in exacerbation and for pneumonia. Cap is also related as acute manifestations of respiratory infection. So adverse reaction not related comp is not related to adverse reaction of dedication for increased mucus production. Same as a BB it's related to a chronic manifestations of COPD, especially during exacerbation and for pneumonia is also related to manifestations of respiratory infection. What about for your heart palpitation? In COPD and pneumonia? There's no such thing as heart palpitations. But heart palpitations can be an adverse effect of medications especially the patient is treated with theophylline so remember to anticipate the signs and symptoms have to fill in toxicity, okay, such as nausea, vomiting, abdominal pain, muscle trend more, okay heart palpitations as well okay. So blood glucose level as we have mentioned 295 Especially during episodes of stress and infection, there is a significant increase in blood glucose, okay. So, it is also important that the nurse should titrate the insulin level and make a appropriate adjustment should the patient becomes especially resistant to the treatment. So in COPD exacerbation because your patient is taking prednisone and consequent steroid, okay. So patient with COPD can have a increased blood glucose due to high dose of inhaled and oral corticosteroids therapy. Okay. So in pneumonia, there is also a manifestations of infection. So therefore, it is expected that the blood glucose will also increase and as we have already mentioned, your patient is taking prednisolone so definitely the glucose level will also increases. Okay, what about for your fever? As I've mentioned a while ago, COPD exacerbation. Fever is unrelated but in pneumonia as we all know fever is the sign of infection. So definitely it is it is common that a patient with pneumonia should present with fever is related as a manifestation of respiratory infection. So for your adverse effect of medication, it's not related for SPO 88% on room air, it's related to chronic manifestations of COPD and worsening exacerbation pneumonia because of respiratory infection and unrelated with the medication so there's no such thing as medication that can decrease significantly the SPO two okay. So now let's move on to Now question number three prioritize hypotheses. So in prioritize hypotheses, where do I start? Ask yourself where do I start based on the recognizing cues based on the analyzing cues, so this time?

To give you examples about multiple response or multiple response, select all that apply question. So let me go ahead read the scenario. But it's the scenario, a 22 year old client is brought to the emergency department by emergency medical service. The client parent found that the client slumped over and unconscious, the client was seated in the wheelchair eating breakfast. When the parent last saw the client 15 minutes prior, the client was bleeding profusely from both risk and the parent reports immediately placing pressure on both risks and screaming to the spouse for help and to call emergency medical system at the scene, EMS reports that the client was unconscious, but the bleeding was controlled, okay, and pressure dressing and continuous pressure to both risks were maintained. So EMS reports that the client BP was somehow decreased by 98 point 9098 over 60 millimeters mercury apical heart rate of 120 beats per minute or about 16. So oxygen or three liters per minute by nasal cannula was administered and the IV line was inserted Okay, an infusion of L R was initiated and the client was transferred to the emergency department. So in arrival at the emergency department, the client is arousal but sleepy. So assessment and treatment are immediately initiated and the client is stabilize in admitted to the hospital, the admission nurse reviews the medical records performs and an assessment and documents in the nurses notes. So let's go ahead read the tab about the health history and vital signs. Okay, so for the health history for the next slide. Okay, so we have for the next slide this health history, this 22 year old. Okay, ma'am. Melanie, can we now move on our slide Okay, for the health history, this 22 year old client sustained a spinal cord injury in the lower thoracic region, one year from a motor vehicle crash, the client has a paraplegia and no other medical problems. So remember 22 year old the client sustained a spinal cord injury into the lower thoracic region a year ago from a motor vehicular crash and because of that the client had a paraplegia and no other medical problems given so what are the signs the vital signs so temperature 101 The client is has a fever because 38.3 degrees centigrade the heart rate of 96 beats per minute BPM 116 over 78 millimeters mercury or 20 beats per minute and oxygen or SVO two is normal at 94% on room air and wrist pain of for over 10 Okay, so what is this nurses notes all about? Okay, the nurses notes so the client is alert and oriented. Okay, is sleepy but easily arousal states is sick and tired of living this way. And it's too young to have to be in wheelchair for the rest of my life. So here so upon reading this statement from the patient, somehow some of you might formulate okay about the possible diagnosis for this patient states. It is my own fault that I am this way I am so sorry that they found me this morning. I slashed my risk using my breakfast knife. I am so useless and do nothing right even with trying to kill myself. The patient has no appetite and is refusing to eat states want to sleep and not be bothered by anyone dressing and both risks are drying in tap no redness or breaking skin integrity noted in other skin areas. No sensation fell in lower extremities unable to move lower extremities last bowel movement one day ago bowel sounds presents in all four quadrants it's normal. So abdomen is fear urinary output of 200 ML in the emergency department via catheterization. But she states she needs to sell catheters every six hours depending on intake. So on no respiratory distress because our is normal at 20 94% on room air for over 10 in risk pain and pain medication administered in the emergency department to our With a goal, and there's no chest pain in the past seem to be normal at 96 beats per minute. So let's now go ahead and read the laboratory results. So, I am injecting this, I am over and over telling you guys when you will be presented with different tabs, please go ahead read all these tabs, because all answers are already on the tab, you just have to read it and analyze it, okay? And try to connect those information's, those data with regards to the presentation of the patient. And so, again, very important to read all the tabs and please avoid skimming. Okay, so please avoid skimming. So let's now move okay. So, what is good about the ng n, they will be given you also the reference range, so you don't have to memorize the reference range, you just have to compare it whether it is it is within the normal limits. So for the test of RBC, 4.7 times 10 So the normal is 4.2 to 6.2. So in WBC 12,000 millimeter, okay. So 5000 to 10,000 millimeters squared is the normal. So with that I can say with the RBC here or 4.7 the result of the patient based on the normal reference, this is normal. Now, let's move on with WBC your patient has obtained a 12,000 millimeters. Mm. So as compared to normal reference range, do you think that is normal? Yes or no? It didn't. That is normal. 150,000 To 400,000 Do you think that is normal? Yes or no? Okay. That is not normal. WBC is high. Remember, WBC is high? Platelets. Okay. 160,000. So normal reference range is 150,000 This is normal yes or no? Is that normal? 160,100 50,000 to 40,000 is the normal range. Is that normal guys? Platelets? Okay, guys, yes. It's not normal WBC, it's not normal. But the question here is platelets. 160,000 Do you think it's normal? Yes, it is within the normal limits? Because the normal limits is 150 to 400,000. What about for hemoglobin? Hemoglobin of 14 grams per deciliter? Do you think that is normal? It is actually normal decent the normal reference range of 12 to 18 and a mattock rate of 42% We think that's normal. It's also normal because the reference range is 37 to 50 to 52%. So based on this laboratory result, we already established that the patient has a significant increase in WBC so the WBC is high. So what is now the question based on this presentation of the data. So let's now move on with the question Okay, what is the question? So, which of the following Okay, are the priority clients needs of immediate concern? So I intend guys again to highlight priority and immediate concern with red so that you will be able to anticipate Okay, the anticipate what is really asking the stem of the question is to identify the priority needs of immediate concern. So select all that apply so let's now analyze Okay, so we have here pain appetite infection, bleeding paraplegia, suicide risk and urinary output, can somebody can someone from the group answer can select answer for this question. So which of the following are the priority clients needs of immediate concern? Based on the presentation? They take? Do you think we can select here pain? Guys, these things we can select here pain?

I think this time is not a priority. Do you think we can also select archetype here, guys? Do you think we can also select archetype here as a priority or immediate concern? I think no. Do you think infection? Dating infection might be a priority needs for immediate concern. Yes or no? We think infection bleeding infection, three side risk. Okay, bleeding infection, three side risks. Okay, so thank you for your answer Monica apatite no Very good. Yes for infection correct Miss Jen Miss Teen yes for infection. So no pain. Not this time for appetite is also no infection. Yes. bleeding here is a prior priority needs of the immediate concern they think bleeding guys, here is priority. Remember going back going back with the with the presentation of the client here states. Okay. So let me read again. So here going back emergency EMS reports that the client was unconscious but the bleeding was controlled. Remember, the bleeding was controlled and pressure dressing and continuous pressure to both risks were maintained. were maintained. So another thing here with the nurses notes. Okay, another here with the nurses notes. Let me check also there's no such thing as bleeding issue with the nurses notes. Okay. So let's now move on. So bleeding. It can be question mark this time. Later on. We will we will rationalize paraplegia. Do you think paraplegia might be priority concerned with this? I think it's not paraplegia is a long term problem it is already exist in existence, even before the patient committed suicide. Okay. Do you think paraplegia ah, miss your Honda is a priority concern based on the presentation of the patient? I think this time is no, but later we will establish why is it? Is it this time? No. Okay, suicide risk. They think suicide rate is a priority concern. Yes or no? Suicide rates? They think? No, very good mistake in Peruzzo. Suicide definitely correct, ma'am. Yolanda. Mr. Mr. Monica, do you think suicide risk? Do you think suicide rates is priority this time? Definitely. Thank you for your time. And Andre. JB room is also Yes. About what about for urinary output at urinary output is priority at this time. Okay, do you think urinary output is priority at this time for your client? I think it's also No, I think it's also no So based on this 1234567 options for select all that apply question. I think the answer is only infection and suicide risks as priority clients need for immediate concern. So let us now establish why is it that is the correct answer? Okay, so remember guys, remember, as I mentioned, ma'am, give me I'll move on for the rationale. So, okay, next slide, please. Okay, okay. So remember, suicide waist, okay. Remember that is an immediate priority. So it is defined as a completed suicide. It is an act of intentional ending in one's own life. self inflicted, and life threatening attempts, but not necessarily it leads to them. Remember? So there are risk factors that we have to establish what are the patients or who are the patients that is predisposed to suicide rates? So number one, so we have your chronic medical conditions. So is it your patient has a chronicle medical chronic medical conditions? Yes, paraplegia because based on the history, the patient sustained a traumatic vehicular accident that affected her thoracic spine, okay. So the your patient has a paraplegic, so definitely a chronic medical condition, okay, affects a person's life ability number two to second factor previous attempt client with spinal cord injury with resultant paraplegia. So, she has or the time they have significant behavior and emotional reactions as a result of changes in her functional ability, body image and also road performance and also the way she look on her self concept. Okay, so what they say In the clients needs at this point, so the client should assess, okay, the nurse should assess client's needs for the reaction. Okay, the client's needs for the reaction to injury an offer you should offer hope. And you should also offer encouragement for this for this matter. Okay, so next, infection is also a priority. Okay, temperature is elevated. Okay, as justified by increased WBC. Okay, WBC based on the rub laboratory result is high. So do you think pain this time is immediate concern, pain is not concerned since she was medicated already. The patient is medicated already two hours ago in emergency department. So it's not any more a concern this time. But as the nurse should continue to monitor the pain start to use. Remember that it's not a immediate concern at this time. But the nurse should continue to monitor for pain status next. Appetite is indeed also not a priority. Although, although the nerves again should monitor appetite status and nutritional intake because this seems to be important, okay. nutritional intake and appetite status is also important. Next bleeding. So bleeding has been controlled already. That's why we do not select bleeding. Because it was stated already that the bleeding is controlled and the dressings are dry and in back. Okay, so there's no such thing as indication that the bleeding is ongoing, because reading as long as the dressing is dry in into so it means to say that the bleeding is stopped. And the laboratories presented a while ago are within normal limits. Okay, we already established that laboratories are within normal limits, except for the WBCs. Number seven paraplegia. Remember that is the sun or problem, but the nurse should plan to address your paraplegia at a later time, not this time. So the nurse can synchronize, can collaborate with occupational therapists, or also physical therapists, but not this time, because again, because again, infection and suicide risks are important. Things that the nurse should focus. What about for urinary output, so urinary output, the nurse should monitor the client. Okay, as stated a while ago, your client requires intermittent catheterization depending on the amount of water or the intake she has. But remember, during in the emergency department, okay, it was seated there, that the patient had 200 ml of urine. So meaning to say the patient doesn't have problem with urinary output. So with that in mind, we can we cannot also include that urinary output is something that the nurse has to be concerned about this time. So the only answer there is yes, suicide risk and infection. Okay, so again for the test taking strategy. So you try to begin answering question by thinking about which client needs know that in the question with respect to the immediate safety implication. So based on this, let's try again. Okay, let's try again, putting it into a table. So that let's identify whether this is a safety implication or something with supporting evidence. So pain, do you think pain is an immediate safety implication? Definitely no, but it has a supporting evidence for over 10 appetite. It's not also a safety concern.

Okay, it has a supporting evidence there. The patient doesn't have any appetite. So she doesn't want to eat. Okay. Is infection and immediate safety implication is also Yes. Is there any supporting evidence stated in the in the history? It's also Yes. Bleeding? Yes, definitely. Okay, it's an immediate safety implication. But the problem is, why is why is it we excluded breathing here? Because in supporting the dance, there is no information that tells that there is an active lien because the dressing is right and intact. Okay? The dressing is dry and intact. So meaning to say bleeding at this time is not a priority. Okay, paraplegia it is a safety implication. Okay. We think paraplegia is an immediate safety implication Definitely no. Is there any supporting evidence that states that bleeding? Sorry, paraplegia should be a top priority? It's also know, what about suicide? Suicide rates? Definitely is an immediate safety implication, the patient use her knife to cut up her risk. Is there a supporting evidence? Yes, because the patient has been rushed in the emergency department. It's unconscious and there is a evidence leading okay. And the BP somehow not within normal limits. So, urinary output. So, it's not an immediate safety implication definitely no, because the patient had to one of you reign in the emergency department, is there a supporting evidence that states that urinary output should be yes definitely because it was said Stay there, stay there, the patient requires a intermittent urinary catheterization. So, this time guys, these are the tapes to be able for you to answer this correctly. So, remember, for this immediate safety implication plus a supporting evidence it both remember this is both immediate safety implications plus there is a supporting evidence that are present within the given information. So, definitely these are the correct answer, these are the correct answer and these are priority however, okay. If there is no immediate concern safety concern, and there is no supporting evidence, you can eliminate it right away eliminate it that is the tip on the other way around if the option would be considered as an immediate safety implication, but there is no supporting evidence you can also eliminate that okay. So, in other word in both safety implication and there is a supporting evidence that is the correct answer, if there is only immediate safety implication and no supporting evidence that is not the answer eliminate that okay. There is a supporting evidence but no immediate state implication you can even eliminate that. So, meaning to say for this for this type of question, both immediate implication and supporting evidence should be simultaneously present okay for you to be able to select it number four, so number four or generate solutions. So, we have your matrix multiple choice, okay, what should you do, what can I do as a nurse for this so let's now move on to number four step four scenario. So, the scenario goes like this the client who is five days post operative following a right collect to meet to remove a bowel tumor calls the nurse and states that they felt a pumping sensation in the in session after an episode of forceful coughing. So, the nurse removes the abdominal dressing and notes that the intercession has opened, when layers are separated and the portion of the bowel April is protruding from the wound. So, here, we can use the word collect to me so how do we define collect to me so collected me is defined as any procedure that removes all the parts of your colon or your bowel? So based on this, the patient had an episode of poor school copying and somehow there is a popping sensation in the incision. So somehow the patient might had a episode of What is it a deceleration or D since the patient had a deceleration okay. So what is the question now? So what is your task for your generate solution? Matrix multiple choice so please an x to indicate Okay, so please add an x to indicate whether each male Can you can you move the slides? Okay, so play place an X. Okay, I think it's not moving the mail. My mail, can we move the slides next? Okay, so, so place an x to indicate whether each potential intervention listed below is either indicated or appropriate or necessary, or contraindicated could be hold a plan of care per client at this time. Okay, so because Nina as I mentioned a while ago your patient has a dissertation so now our task is to identify whether these interventions listed can be indicated or contraindicated based on the scenario so please the client with the head and body flat and with the hips and knees then do you think that is indicated or contraindicated? Placing the client with the head and body flat and with the hips and knees bent that is contraindicated later on we will rationalize why said Next place a sterile warm area or warm saline rather soap dressing over the open wound. Is that indicated place a sterile warm saline soak dressing over an open wound? Is that indicated saline warm soap dressing over an open wound? Do you think that is indicated or contraindicated guys okay, so our so it's up to you later we will we will we will rationalize that we will rationalize that. So is it placing a sterile warm ceiling so dressing over the open wound? Tree Dawn sterile gloves and gently insert the protruding gently insert the protruding bow into the wound? Do you think that is indicated or contraindicated? provide the client with small amounts of water or juice to stay hydrated. Is that indicated or contraindicated? Notify the surgeon. Do you think that is indicated? Yes or no?

Prepare the client for surgery Do you think that is indicated? or No? Or last assess vital signs every 10 minutes? Do you think that is indeed indicated? Yes or no? Now let's move on to rationally. So let's now explore the answer. Okay, so as I mentioned a while ago evisceration we define immiseration as a total separation. So total separation of worn layers in the protrusion of intestinal organs outside through the wound. So this is usually between it happens between Fifth and 10 days after the surgery. And it be separation can be common to the following condition so evisceration can be common to the following condition. Number one, if the patient has a patient, it's unknown diabetes, okay. As diabetes mellitus, the patient is malnourished, the patient has a immune deficiency or the patient is taking steroids, okay medication why? Because diabetes, malnutrition, immune deficiency and use of immune of steroid medication may somehow delays the healing process. Okay, it delays the healing process. Okay, so remember that your immiseration is a surgical emergency. So when that happens, the nurse has to stay, the nurse has to stay and you should call another nurse to notify the surgeon and since that is an emergency situation, it is also imperative that you call the rapid response team immediately and bring the supplies needed as necessary. So while you're there, while you're there on the patient's one, you should provide reassurance you should provide reassurance and position the client immediately in supine. Okay, remember this position the client in supine with the hips and knees bent and with the head of bed elevated at least 15 to 20 degrees. This prevents stretching of the abdominal tissues and prevent pressure on the incision line which would worsen the condition using this sterile technique. Yes, it's correct. You should apply one to large abdominal dressing to put it in the area. But prior to doing that, you should be able to saturate it first with warmth. That is correct. So therefore saturate it with our normal saline to the woman why this is to prevent hypothermia. Okay, this is to prevent that is the important thing to remember saturating It would warm sealing water in the to prevent hypothermia and provide moisture barrier to the tissue and protruding organ. Okay, why is it become again warm because you really want to prevent hyponatremia to happen and you should not attempt remember this you should not attempt to re insert the protruding Oregon okay the protruding Oregon because it might cause trauma to the Asian this might cause trauma to the patient and always monitor vital signs every five to 15 minutes remember this monitor vital signs for five to every five to 15 minutes until the surgeon comes or arrives and Please be certain to monitor for signs of shock. Okay monitor for signs of shock. Okay so what is the signs of shock hypo tacky, okay, place the client in NPO to decrease the risk of aspiration if surgery is necessary. Remember that Okay, so next test taking strategies Okay ma'am for okay for your test taking strategies. This the client with the head and plan about the plot and within the hips and knees bent No, because this may cause further tissue disruption from pressure on the incision line. Placing a sterile warm saline soak. Okay, dressing over the open wound. This is yes to prevent hypothermia, and provide moisture to the affected area. Donning of sterile gloves and gently insert the protruding bowel into the wound is no mirrors you might reintroduce or introduce trauma to the patient. Providing the client with small amount of water or juice to stay hydrated is always no because you have to put your patient to NPO should surgery necessitate okay to prevent the risk of aspiration you should notify the surgeon this is definitely yes. And the nurse should be able to anticipate additional orders that a doctor should ask and also determine the details about the surgery. If so, if surgery is is going to happen and prepare the clients for surgery, definitely yes, this could repair the surgical site and assessment of the vital signs every 10 minutes is Yes. Especially important in monitoring for signs and symptoms of shock. So what is again the signs and symptoms of shock hypo tacky. Okay, so now let's move on. So the number five is your take actions or your matrix multiple response. So what will I do? So the scenario is a 65 year old client was hospitalized in treated with symptoms of heart palpitations, and extreme shortness of breath and admission. Diagnosis studies showed the following. So the patient had atrial fibrillation CT revealed negative for embolism and chest Ray chest X ray revealed enlarged left ventricle. So the nurse is preparing for the client to for discharge and provide teaching about prescribe medications. So for each medication listed, click in the box to specify the teaching point the nurse would provide to the client each teaching point may support more than one medication. So can we now move on. Next slide please. Okay, so for each medication listed click in the box to specify the teaching point the nurse would provide to the client each teaching point may support more than one medication. Okay, so now, we have here three medications we have amiodarone, Metoprolol, and warfarin. So let's now focus on the teaching point whether this is applicable to any of the medications stated. So yes, routine laboratory monitoring. Do you think that is applicable for amiodarone and Metoprolol? I think that is only applicable for warfarin. So monitor and report signs of bleeding. I think that is also

the teaching point for librarian and not for amiodarone and Metoprolol. Monitoring for shortness of breath. It's not also teaching point for amiodarone and multiple Metoprolol. But I Sorry, sorry, monitor and report poor shortness of breath is not a teaching point for water Perine but rather, a teaching point for me Know the role and Metoprolol monitor BP and heart rate. Okay, that is a teaching point for amiodarone and Metro Metoprolol, but not for war Perine and consume consistent amount of green leafy vegetable is not a teaching point where amiodarone and Metoprolol but rather a teaching point for warfarin. So let's now move on with the rationale there. Remember that your internationally amiodarone is an anti, it's an anti dysrhythmia. Okay, it's an anti district MC medication used to treat atrial fibrillation. So, it causes blood vessels dilation, remember that amiodarone causes blood vessels dilation and can lead to D for dizziness and hypotension. amiodarone can cause dilation of the vessel thus could lead to dizziness and hypotension. So, whenever the patient is taking amiodarone you should be sure client to check his or her heart rate. Remember checking for the heart rate and blood pressure. Okay, blood pressure because the adverse effect is usually pulmonary toxicity. So, what should you what should the nurse anticipate if there will be a pulmonary toxicity if there is shortness of breath okay, if there is hear shortness of breath, the nurse has to call the position or the caregiver immediately okay remember this next Metoprolol is a better ad dynojet blocker, your Metoprolol is a better adrenergic blocker and cost her heart rate and BP to decrease. So, remember your Metoprolol is a better adrenergic blocker and causes your heart rate and BP to decrease. So, each time your patient is taking Metoprolol the nurse should make sure to teach the client that heart rate and blood pressure are within normal limits or within normal limits as it may cause Okay, as it may cause shortness of breath okay, it also causes shortness of breath, caffeine and also we sing. So if you see coughing shortness of breath and we seen the patient who is taking Metoprolol please notify the position immediately Okay, Please also remember that both amiodarone and Metoprolol clients should be thought of okay should be thought safety measures clients should be thought safety measures should such as moving slowly from sitting or lying to a standing position okay to a standing position and immediately if the patient okay. And if the patient feel somehow business, the patient or lightheadedness, for example. The patient has to immediately sit down or lie down. Okay remember that sit down or lie down during these illness or lightheadedness and Warfarin so Coumadin. So normally normal Coumadin, so we have 0.9 to 1.8 per second so we have the therapeutic of up to three times. So bleeding tendencies if the result is more than 3.5 seconds. Okay, so remember that an anticoagulant, okay requires anticoagulant requires routine laboratory monitoring, routine laboratory monitoring for coagulation studies, especially, okay, INR or what we call international normalized ratio, and the dose adjustments are made based on the INR. Okay, so another points to remember with your warfarin, your Warfarin slows down clotting, and the adverse effect is bleeding, then monitor and report definitely, the nurse should monitor and report signs of bleeding. So green leafy vegetable contains vitamin K, which is an antidote for warfarin. So meaning to say you had to be certain as well, that when your patient is taking warfarin, the saints are taking warfarin and he or she is eating green leafy vegetable. As we all know, your green leafy vegetable contains vitamin K, it is a mastery to remember and to explain to our patient that the patient should only consume a consistent amount of green leafy vegetable. So the vitamin K from this food remains okay remains at a consistent level remains at the consistent level in the body and does not inhibit the effect of warfarin. Okay, so now move on. So let's now move on with this takings tips. Okay, there you go. So waterboarding is an anticoagulant is a long term prophylaxis of thrombosis, but it's the side effect of your Warfarin B stands for bleeding. So what is your primary nursing consideration or teaching points, you need to do a multiple drug the drug, it may cause multiple drug to drug interaction or fourth interaction, so the nurse should perform medication reconciliation, the nurse should review diet monitor bleeding, monitor for signs or bruising for example, urine stool and safety measure for example, the nurse has to tell the patient to use only soft bristle toothbrush and use of a electric shaver when she been because of having this bleeding tendencies. So on the other on amiodarone is a treatment of choice for atrial and ventricular dysrhythmias, atrial and ventricular dysrhythmias with a side effect of pulmonary cardiac and thyroid toxicity and auto sensitivity. Okay as part of the be atomic effects. So what are the primary nursing consideration monitors signs and symptoms of toxicity? measure heart rate and BP report lightheadedness or dizziness? Okay, so last one, last one, we had the word Metoprolol. We already established that this is a better adrenergic blocker. So what are the indications of Metoprolol? We give me Dr. A lot of the patients with hypotension hypertension patients with angina patients with heart failure in patients with myocardial infarction. What are the side effects of your metal of your Metoprolol bradycardia reduced cardiac output heart block rebound and cardiac excitation and the nurse has to monitor the following measure the heart rate and BP measure and report immediately tell your patient if he or she is having these adverse effects such as lightheadedness, dizziness, cough and wheezing because that necessitates information that the doctor should know okay, because that is a toxicity

Okay, so next. So last question would be evaluate outcomes. So in evaluate outcomes so we have here the highlight text examples a scenario would be at the old newborn is seen in the outpatient pediatric clinic for a post hospital follow up appointment. So the nurse reviews the health history and notes the following. So the implant born full term via vaginal delivery, no labor or birth complications. So the birth weight is seven pounds or key ounce or 2.3 kilograms, the birth length is 19 inches. So laboratory revealed that bilirubin is 3.1 milligram per deciliter as compared with the normal reference value. It seems that the result is is a little bit high is obviously high. Okay. 3.1 or PT 2.7. So next. So the question here is, the nurse performs an assessment on the newborn and obtains a blood specimen for evaluation of the bilirubin level. So the following notes are documented. So your task is to click to highlight the findings that indicate the need for follow up in a 3d or newborn. So again, as I mentioned a while ago, very essential thing to remember when you will be presented with different tabs. So please take time to read all the information in all tabs because the answers are there already. Okay, so nurses notes, breastfeeding, just feeding. Okay, every two to three hours without difficulty. Parents report infants urinate 12 to 15 times per day and has a bowel Have movement of five to six times per day. So the report they report that the stool is greenish brown to yellowish brown, then in this sticky inconsistency than it has been, they have noticed that the skin looks tan in the eyes looks yellow. So the vital signs revealed 99.6 degrees Fahrenheit or 37.5 degrees Celsius for axillary apical heart rate of 180 beats per minute and regular RR or 170 beats per minute and the weight is seven pounds or five pounds or 3.4 kilograms. So the bilirubin here Okay, so the bilirubin seems to be high, okay because 4.8 milligrams per deciliter is the result and in according to normal reference range, the normal is only 0.2 to 1.4 milligrams per deciliter. So based on this so our task is to highlight the findings so based on the nurses notes, okay, we can highlight here they have notice this the skin looks tan and the eyes look yellow, so we can highlight that in the nurses notes. Okay, what about for your vital signs? 37 degrees Fahrenheit point five degrees Fahrenheit is not normal. The patient is somehow a BReel Okay, the patient has a beverage or has a fever. Okay, the optical path is 180 Okay 180 beats per minute. So we can even highlight that and also highlight this bilirubin result of poor point eight. So next so rationale layer. So let's now move on to the rationale. So remember this unconjugated bilirubin? Remember guys unconjugated little bit bilirubin normal is 0.2 to 1.4 milligrams per deciliter. This is basically a pigment that is increased mostly in infants with neonatal John this is the bilirubin associated with normal destruction of all the red blood cell. And thus we call it a special logic John this. Remember with unconjugated bilirubin that high levels of unconjugated bilirubin can result in damage to the basal ganglia in the brain, thus causing chronic T rules and damage to the eighth cranial nerve resulting to sensory neural hearing loss. So it is important again to remember that the normal values of unconjugated bilirubin and the damage it can cause to basal ganglia to a patient with visual logic join this exceeded at five milligrams per deciliter it is called a John this and John this can be pitched to logic and it could be pathologic. So remember with pitch Fisher logic John days, it doesn't present on day one. But in pathologic John days it presents during the first day of life which is an abnormal finding, and should raise concern and always require further evaluation. So hyperbilirubinemia is a condition where your patient is currently having this of course when excessive amount of bilirubin accumulates in the blood, as evidenced by mild and self limited patient logic John These are also known as your epi rose Neo natal room. So let's  go ahead and analyze the following information. They think tank colored skin and yellow eyes are not are not expected. Okay guys, do you think your tongue colored skin and yellow eyes are not expected? Definitely they are not expected if we are telling here or speaking here official logic John this since your patient is having a pathologic don't they so definitely this tan colored skin and yellow eyes as normal or not. Okay, they think that it's normal or not. Okay, this is this is normal. Okay. So, next, so urinating 20 times during Do you think urinating 20 times is expected Okay, urinating 20 times is expected and that is normal. Okay, urinating 20 times is expected and that is normal because the bladder in both voluntarily MPs when stretch at the volume of 50 and milliliters in infants. So infants are bladder that already holds at least 15 milliliter of You rain, so, definitely there will be a involuntary or voluntary bladder emptying. So, so, it is normal or expected that the infants should have urinate for at least 20 times okay 20 times So, that is normal transitional stool appear by the third day after initiation of feeding in greenish brown to yellowish brown thin and less sticky than meconium stain so, we call him stain is abnormal, but we cannot we cannot rule out meconium stain here these are also So, expected so, what is normal vital signs for infant okay temperature 36.5 to 37 that is normal typical height is normal if it is only within 120 or 140 beats per minute or 180 It's not normal. So, as presented a while ago the patient had a 180 beats per minute so, that is not normal or 30 to 60 cycles per minute is normal and the patient weighs is 2.5 I think okay, so the average birth weight for babies is around 3.5 kilos or 7.5 pounds, although between 2.5 kilograms or 5.5 pounds and 4.5 kilograms or 10 pounds is considered normal. So 3.4 kilos is normal. So it's within the normal limit and the serum bilirubin remember that the serum bilirubin peak on the poor and usually reduces at day 14 Okay. So, the serum bilirubin a patient is 4.8 so, definitely, definitely that requires a follow up that concerns us that because there our patient is considering is having rather a pathologic join this Okay, so last for the test taking step test taking tips here, okay, remember, you need to list down again the findings, then ask yourself if that is expected or normal outcome or unexpected or abnormal outcome or not record not requiring follow up breastfeeding just feeding every two to three hours without difficulty. That is a normal outcome

during 812 to 15 times a day that is also normal outcome had bowel movement five to six times per day that is also normal outcome. Stone is greenish brown, yellowish brown, thin and less sticky inconsistency that it has been. It's also a expected or normal outcome. She looks done and looks eyes and eyes look yellow, that is an abnormal that is already a John this. And we already established that your patient has a pathologic John this okay, temperature of 99.6% or 6% Brothers degrees centigrade. That is an expected and expected outcome. It requires follow up an apical heartbeat of 180. That is also an unexpected outcome. There are about 70 Okay, it's also an unexpected outcome because until 60s, maximum, and serum bilirubin of 4.8 is also an expected outcome. Okay, so I think so I think that ends the examples for the test taking strategies for different tests, or following the clinical judgment in as part of your next generation NCLEX which will be implemented this first of April. So I wish for those who have stayed until the last part of this presentation, I wish you good luck, if ever you will be taking the next generation and legs. And hopefully this topic will give you opportunity to identify the most important tips and strategies that you can effectively use during your examination. So I wish everyone a nice evening or a nice day. So from the Philippines or on behalf of iPass in behalf of Connetics. So thank you so much and see you all again. to our next Connetics college free live session so thank you so much and have a nice day have a nice day bye