NCLEX Bootcamp Case Study Overview

We'll take just a second longer to let some more people show up and then we're gonna get started. Couldn't have done it without this program. Well you're very welcome. We're very very happy to help. We're so excited that all of you are here. We love helping students pass the NCLEX and yeah hopefully you know you're gonna go on to be a better nurse because of it. Perhaps some Ron. I hope I'm not saying your name wrong. Thank you. We love our rationales too and thanks for joining Very good. So, okay. We're gonna go ahead and get started quickly If you guys see me looking off the side of the screen here, I'm watching your comments separately So yes, I am Dr. Emily. I'm one of the co-creators here at NCLEX Boot Camp. We've got Dr. Amber in the chat moderating, gonna be answering your questions. I'm gonna be watching your comments as well. There might be a little bit of a delay. We're not ignoring you. We're gonna try and get to everybody's questions by the end of the thing. But yes, thank you so much for joining us. We're so so happy that you're here and we're gonna be talking about answering next-gen case studies. So first we're gonna look at the NGN case studies. study format, what it looks like, and then most of our time we're going to spend practicing going through a case together so that you guys can get that practice thinking like a nurse, which is really what we want to teach you here at NCLEX Bootcamp. So first, the case study format. So each case study on the NCLEX is going to have six questions that corresponds to each of these six steps of the clinical judgment measurement model. And you might not be familiar with this, but you've probably seen the nursing process before. your ADPIE and this is really similar this is essentially just the thought processes that we go through in every single patient encounter and so that starts with recognizing cues or assessing out of everything that's going on what's most important here analyzing those cues or considering what could it mean or what disease processes or diagnoses is that associated with prioritizing hypotheses so figuring out what we start with first generating or planning what what solutions or interventions we can take to address those problems, then actually taking those actions and evaluating if they helped. So we'll go through each of these steps in detail as we answer the case together, but this is ultimately how the case is laid out. And you are gonna have three full-length case studies on a 85-question test. That means it's gonna make up for three cases, six questions each, about 25% of your score. If you have have a longer test than 85 questions, you're gonna see additional clinical judgment items in the form of trend and bow tie items. So, but either way, this is gonna make up a big chunk of your test because this is really important. This is kind of the heart of nursing. The NCLEX is a safety exam, that is true, but it is also a clinical judgment exam starting with NextGen where we need to make sure that we can think like nurses to keep our patients safe. So we'll get some practice doing that together. So let's do it. Let's practice thinking like a nurse. And we're going to be walking through one of our cases together. And I want to know from you guys, how many of you were actually able to practice next-gen cases in school? Like in your nursing program, let me know if you had some kind of school-provided next-gen case study practice or if you had to go somewhere else to practice next-gen cases. I think it's really hard to create these really well and so we've got 50 case studies on our website for you to practice with. So Keir said not me, neither did Verona, so yeah it's... it's really kind of hard to come by good solid next-gen case study practice. So we're going to walk through this case today, but yeah, we've got 49 others on our website that you guys should definitely check out. And Amber's going to make sure the link to our stuff is down there for you. But yeah, this is basically what it looks like. The big difference in the next-gen cases versus your standalone NCLEX items is you've got a lot more information. You guys might have heard that the NCLEX is vague and that is true for the standalone items. You only really have enough information to answer the question, but that's not real life. In real practice, our patients never have just one problem in isolation. They never have just pneumonia, right? They have so many different things going on. Their chart is full of information and we want to make sure as the first step that we can get the right information out there. that we can recognize cues or figure out what's most important here. So in the case, you'll be able to click through all your tabs just like you would in a real patient chart. And that when you are recognizing these cues, reading through these client data tabs, I want you guys to really practice every single time envisioning this scenario closely. Try and Keep this mental picture in your mind of what's going on with the patient and always kind of have in mind what you think your priority problem or priority problems are. So don't lose sight of that, try and keep that in mind as you progress through the case. course at any point if the case client data tabs update or you get new information revisit that mental picture there are things that can happen in these case study updates you can move from the ER to the OR or from the ICU to step down or even be discharged home. And so make sure you have this mental picture of what's happening with the patient at each step in the case. So let's take a second envisioning this scenario closely. I'm gonna kinda click through and highlight important things. Of course, on the real exam, you guys are gonna have a whiteboard that you can use to kind of note anything that you think is really important to keep in mind. All right, so keep all this in mind. We've got this 57-year-old client. He comes to the emergency department feeling short of breath and having a cough for the last few days. He's been sleeping on two pillows, waking up coughing. He's felt very fatigued and spends most of the day in the bed or the chair. He appears anxious and then he has got this long history of cardiovascular risk factors, hypertension, hyperlipidemia, chronic stable angina, type 2 diabetes, and he's worried that he can't afford his medications. So reminding you guys to keep this mental picture in mind as we move on. This relatively young gentleman is short of breath, he's coughing, he's anxious about it, he's sitting upright. Keep that mental picture in mind and add to it as we continue reading, alright? So in our assessment we see he's oriented, that's good. He's got crackles in his lungs, he has an S1, S2 and an extra S3 heart sound. His bowel sounds, cap refill and pulses are all normal and then he's got one plus pitting edema to his lower lower extremities. So on top of this picture of shortness of breath, staying upright, he's also got edema and extra heart sound and crackles. Keep all this in mind. Then we look at our vitals. We see that he's afebrile. He's a little tachycardic, little tachypneic, little hypertensive, and then our pulse oximetry reading is low. So keep all this mental picture. And I want to ask you guys, I kind of see two priority problems here, two big things that are happening. what would you guys say your priority problem is? Drop it in the chat what you think is kind of the priority thing that's going on. Because I think there are two, and I think we all see the first one is maybe the shortness of breath, right? He can't breathe. We don't need to overcomplicate it. He can't breathe. He's having a hard time breathing. We've got the dyspnea, the low pulse oximetry. What might your other problem be, your second priority problem? So in addition to these respiratory problems, findings what other things are you guys seeing here what are the problem Yes, Jackie, the shortness of breath. Definitely that respiratory insufficiency is, I think, a big one. Shan says the crackles, definitely. So yeah, we've got these other signs that really make it seem like maybe he has too much fluid on him, right? We've got swollen lower extremities. The extra heart sound, the S3, is always going to indicate fluid overload, right? So we've got somebody who's short of breath with some fluid overload. So keep this mental picture and those two priority problems in mind. So, all right. Now we want to consider what's most important here. You saw there was a lot happening, but there are only a couple of things that are most important. And the NCLEX might ask you that as what requires immediate follow-up or which two, three, or four findings are most concerning. So as we consider that, try and figure out what are our unexpected abnormals that we're looking for. And if you're being asked about how to follow up and you're not sure, always kind of have in mind how you... you would follow up? What would it look like if I was going to select this option and follow up on that? So let's keep that in mind. So of these findings, we want to select the top four that require immediate follow-up. So we're looking for unexpected abnormals that we can do something about. And keep in mind that for a select N, so if you're told to select two, select three, select four, you always want to select the maximum number possible because you won't lose points for selecting an extra option, if that makes sense. So in a regular SATA only select the ones you're sure of if you're being asked to select a certain number always select that Full number never leave one off All right So let's go through and we're only going to select at first the ones that we are 100% sure Require immediate follow-up and nothing could convince us otherwise. So let's take these One at a time. What do you guys think for cough? Do you think that we need to immediately follow up on the cough? Yes or no? Is that something that requires immediate follow-up? So when I think, is this an issue of airway, breathing, circulation, it might be related to a respiratory problem, right? Maybe an upper respiratory tract infection, but Shan, I... with you. Shan says no and I agree. We really don't want to follow up on that cough right now. There's nothing that I would do about this right now. So great, the edema. So what do you guys think? Is the edema something that I want to follow up on immediately? Because it is potentially an issue of circulation, right? But, okay, Shan thinks yes. I'm not so sure because if I know that one of my issues is he's having trouble breathing, breathing, he can't breathe, I'm probably going to hang on for some respiratory findings first. But I'm going to keep this in mind. This might be a good priority issue. Crackles. Okay, Jackie says crackles. Yes, I agree with you. So yes. when you hear crackles that means something is happening in the lung that's interfering with gas exchange and we have evidence of that right we've got a low pulse oximetry reading so these crackles tell me something's happening that's impairing his respiratory status good how about the respirations do you guys want to address those immediately yes Mariana Courtney says yes I agree that tachypnea is compensatory right if you've got a low pulse oximetry which hypoxemia is our next option here then your body's gonna compensate by increasing that respiratory rate to try and get more oxygen delivered into your lungs because it's not picking up enough and carrying enough good all right so we've got three so far is blood pressure our fourth what do you guys think do we need to immediately follow up on this blood pressure So Shan says, no, Shan, you're killing it today with these. I agree with you. So I'll ask you this about the blood pressure. Is it expected or unexpected for this client? This blood pressure of 149 over 93, expected or unexpected? So I'm gonna point out here this guy's got a history of hypertension, right? So he not only has high blood pressure, but he's also told us that he's been concerned about affording his medications Maybe he hasn't been taking them. So this might just be his everyday blood pressure. Yes, I agree with you guys. I think this is expected. If he had some unexpected signs of high blood pressure, like a really severe headache or blurred vision or mental status changes, then I might prioritize. that but he doesn't I think this is expected and we can ignore it good shortness of breath what do y'all think I think you guys I think you guys know what to do with this one should we follow up on the shortness of breath and yes definitely so that is part of our big picture respiratory insufficiency but let's consider our last two options just to be sure how about his inability to afford medications well there's nothing really I can do even though it is obviously very important that we get our patients access to their medications and their care. That's not something I'm gonna immediately follow up on as a psychosocial issue. I'm not gonna call a social worker in here while he is sitting up breathing hard fast with a low pulse oximetry. Same thing with the history of chronic stable angina. How would I follow up on that? Just like ask him things about his history, how well it's controlled. There's really nothing for me to do about this. It is gonna help us inform what might be causing his symptoms but it is not higher priority than these. these signs of respiratory insufficiency are crackles, tachypnea, hypoxemia, and shortness of breath. And we're correct, well done you guys. So average score on this was only one out of these four. So you guys who got all four are way ahead of the curve, well done. All right, so our next question in CJM cases is going to be analyzing cues, or then figuring out what could it mean? And the NCLEX might ask you what conditions are the clients experiencing or at risk for experiencing? experiencing, what disease processes could cause these findings we're seeing, or how would you know if X or Y disease was happening? So keep in mind the big picture. We've considered in the previous questions the individual findings. Now you want to think about the big picture and specifically consider some specific versus non-specific findings. And shortness of breath is a very common non-specific finding. It could mean a hundred different things. So I want you guys to drop in the chat. What are anything that you can think of that would cause? Shortness of breath because there's just so many things I'll start naming a couple with you. I think we have the obvious. If we start ABCs, we could have any kind of airway issue, right? Maybe smoke inhalation or in a child, like an epiglottitis, breathing. so Shan says asthma definitely Miriam says COPD for sure these can cause breathing issues maybe pneumonia yep Brianna got it pneumonia how about some circulation issues are there any circulation issues that can cause short breath shortness of breath. Okay. AK says CHF. Yes. Cardiac problems, Mariana. Very good. What about something like anemia, right? We don't have enough oxygen carrying capacity in our blood. Maybe a pulmonary embolism. We can't get blood flow to the lungs. So you can kind of see there are so many different things that can cause shortness of breath, and it's not a very specific finding. But then we do have some specific findings that might be associated with it. So for example, think Think about a patient who has shortness of breath and we think it's pneumonia. What other signs and symptoms that that patient had might make us think it's pneumonia? Like what other findings apart from the shortness of breath would point you toward pneumonia? Think like vital signs, lab values, symptoms. What are some specific findings? Fever, definitely. AK's got it. Yeah. Fever, white blood cell count might be elevated. Maybe they've got a... productive cough, so they're coughing up yellow-green sputum. So if our nonspecific finding is shortness of breath, our specific finding might be the fever, the sputum, the white blood cell count. So we wanna consider the big picture here as we go in to analyze these cues. And we need to figure out that crackles throughout the lungs in this client are due to either infective infiltrate, collapsed alveoli, or fluid accumulation related to either pneumonia, heart failure, or reduced mobility. So crackles is what we're thinking about here. And any of these things could cause crackles, right? Have you guys had an opportunity to actually listen and auscultate crackles in your clinical sites? Or maybe if you're already working somewhere? chance to hear this before. Sounds kind of cool. It's described as like that snap crackle pop sound and if you've never heard this in your patient you can actually just take, so Shan hasn't heard it, you can grab a little piece of your hair and kind of roll it back and forth between your fingers and it creates that kind of snap crackle pop noise and that's what crackles sound like. And so this is described to me as, think of it like you're blowing bubbles through a straw is what you're hearing. You're hearing air passing through fluid or if alveoli you'll like collapse, they can kind of pop open in the inspiration. So any of these things can cause crackles. And in this client, do you guys think that these crackles are due to an infective infiltrate, yes or no? So infective infiltrate is just a fancy word for pus, right? If we've got pus, infectious material in the lung, obstructing the airflow, which condition would infective infiltrate be related to, you think? Pneumonia, heart failure. or reduce mobility good you guys are saying no I agree I don't think so either so of these conditions we talked about pneumonia being the infectious one right so I don't think it's that in this client I agree with you guys now how about collapsed alveoli which of these conditions would cause alveoli to collapse Pneumonia might cause the alveoli to collapse, but you guys remember after a patient has surgery or when they're really immobile For example, this guy's been spending most of the day in the bed or the chair. They can start to have atelectasis. So although he's at risk for this if you're ever here if you ever hear crackles if you ever hear that snap crackle pop in your patient's lungs you can ask them to cough and that's gonna clear those so if you're if your crackles clear with coughing say that three times fast then you know that they were probably due to atelectasis. And this guy's been coughing for two days, he's been coughing all night. So I would have expected these crackles to clear if they were due to atelectasis. So then that leaves us with fluid accumulation, which you guys all, I think, want to pick and have pointed out that's related to heart failure. So how would crackles cause, or how would fluid accumulation cause crackles in heart failure? Let's talk about that. So in heart failure, there are two major risk factors that would strain your heart muscle so the two big ones are high blood pressure, which our client has and coronary artery disease a lack of blood flow to the Heart so if you have high blood pressure that hearts gonna have to work harder to pump if you have a lack of blood flow To the heart. It's not getting enough oxygen supplied to it to pump So those result in this ventricular dysfunction where the heart doesn't have enough squeeze It can't squeeze blood forward and so instead that fluid can back up into your lungs Filling the alveoli and cause that blowing bubbles through straw kind of sound when you listen to it So yes, I think that that is our correct answer and we're correct well done again only about half people got this so you guys are doing a great job so next after analyzing cues we want to prioritize hypotheses or consider where do I start and the NCLEX for this might ask you what is the client most likely experiencing what are they at highest risk for or what do you need to do first and when we're talking about prioritizing I always like to kind of keep this question in the back of my mind of if I can only do one thing for my patient and walk away, what should that one thing be? All right, so we are gonna prioritize hypotheses here and we're being asked about risk. So this client is at highest risk for developing either respiratory failure, acute kidney injury, sepsis, or pulmonary embolism, and we can pick two. So our two biggest risk factors. What do you guys think might be one of them? I think as we start top to bottom, do you think this client is at risk for respiratory failure and that that's gonna be one of our two? highest risks. So yeah, Shan says yes and I agree. Remember that was our number one priority issue we identified from the beginning and we want to keep that picture in mind. This guy can't breathe. Of course we're worried about respiratory failure. He's got low pulse oximetry. He's hypoxemic. I'm definitely worried about that. How about acute kidney injury? How would heart failure cause acute kidney injury? Okay, you guys are saying yes. Alright, so let's think about this. Acute kidney injury is a form of organ failure, right? And whenever you've got this ventricular dysfunction, not only is that blood not being pumped forward and back. up into the lungs but because it's not being pumped forward it's not reaching the organs either as well and so your kidneys depend on 25% of your cardiac output every milliliter of blood that leaves your heart 25% of those go to the kidneys And so your kidneys are gonna be affected first if you have a decrease in cardiac output and you can start to have this reduced end organ perfusion and organ failure. So definitely I'm worried about acute kidney injury. I don't know if it's one of my top two yet though. So let's put a pin in that. So sepsis, what kinds of things put clients at risk for sepsis? What condition would put this guy at risk for sepsis? So if sepsis is an infection of the bloodstream, right, you would have to have an infection somewhere else first. So maybe a pneumonia or some other infection. We've already pointed out we don't have any evidence of infection. We don't have a fever. We don't have purulent sputum. this is unlikely. How about a PE? I think I saw somebody say that at some point. What puts someone at risk for a PE? What other disease process? Because a PE starts usually where? In the legs, right? Good. Very good. So for sure. I don't think he has a PE or a DVT right now because we only have, we have pitting edema in both lower extremities. If we had it in just one lower extremity, that might make us think he has a DVT, which would be a risk for a PE. So although he is at risk for all of these things, he's been immobile, so he's at risk for a DVT. He obviously is hospitalized or going to be. so he's at risk for infection just because we're touching him. But of the ones that we saw, yes, the respiratory failure and the acute kidney injury or really any form of organ failure are the two big ones. And we are correct, well done. So all right, next. Our next step is gonna be generating solutions or after identifying this priority problem, we need to figure out what can I do about it? So the NCLEX might ask which interventions are indicated or not indicated, which are gonna address that priority problem or which could work. worsen the priority problem. And so I wanna point out here that this depends on your understanding of the content, because the same symptom we could treat two different ways if it's from two different disease processes. So how would you guys treat shortness of breath from pneumonia? What medication would you give? So to treat any sort of infection, we would need to give antibiotics, right? versus shortness of breath from a pulmonary embolism. What medication would you give for that? Okay, Jackie says furosemide might be, all right, albuterol, so yeah. The furosemide for fluid, albuterol for bronchoconstriction. I was thinking antibiotics for pneumonia or heparin for a PE, right? So same symptom, four different treatments. So you guys gotta understand the content and that's why we're talking about heart failure in detail. So now that we need to actually generate solutions, let's consider each one of these. Do we need to get blood for a blood culture? Is there any reason that we have to want to get a blood culture for this guy? So that would be indicated for someone who we do think has an infection, right? If they have the fever, if they have the purulent sputum, same thing sputum for culture. We don't even know that his cough is productive. That is not anticipated. So I'm not going to select these. Then preparing for an echocardiogram. Does this gentleman need an echocardiogram? What do you guys think? What do you think about if he should get an echo? Okay, I can't tell if our no's are from the previous option or not, but Shan says yes. Shan, you should come to our webinars every week. But yes, I definitely want to get an echo, because in an echo, they're able to actually visualize the heart. They do this at the bedside, and we can see. how much blood is being pumped out of the heart with each beat and that tells us about the cardiac output and heart failure is a problem of cardiac output so I definitely want to do the echo. What about serum renal function tests? Do we need to do those? Sabrina says yes. Carmel says yes. Yes, not only do we want to check for the acute kidney injury that we're worried about, but we also might be giving a medication that we need to check the renal function for. What medication do you guys might want to give this guy soon that we need to know his kidneys are functioning for first before we give it? This is a big NCLEX test thing, so make sure you know this. What medication would we want to look at his renal function for? It's gonna be the Lasix, right? The furosemide. Our loop diuretics are nephrotoxic, so we don't want to give him the loop diuretic until we know that his kidneys can tolerate it and that he's not in renal failure. So I definitely want to do this. Oxygen. Does he need oxygen? Yes, I think you guys know that. If his pulse oximetry reading is under 90%, he needs oxygen. So we are going to give him some oxygen to titrate to keep his pulse ox greater than 90 to 94%. Do we need to get a 12 lead ECG? We need to hook some stickers up to this guy and see what his heart rhythm is doing. Okay, you guys are saying yes. Yes, because we don't know if his heart failure could be caused by maybe a heart attack or atrial fibrillation. He does have all of the risk factors for a myocardial infarction, and myocardial infarction is the number one cause of cardiogenic shock, which is an extreme form of heart failure. So definitely I want to get a 12-lead EKG and make sure his heart is not... not failing because the muscle is dying basically then draw serum b-type natriuretic peptide do we need to get this do we need to get a b-type yes Michelle says yes for sure because the B in P is released when your ventricles stretch so if we have a high B and P in the blood that tells us that those ventricles are being stretched from fluid overload it tells us about the severity of heart failure so yes these are the things I want to do for this guy right now get him some oxygen and then do a quick workup with an echo to visualize his cardiac output make sure his kidneys are doing okay before we give him any Lasix get the 12 ad kg make sure he's not having an MI and then get the BNP to diagnose the severity of the heart failure and we're correct very good alright so next we need to look at taking action or what will I do should I do it how do I do it the NCLEX wants to know that you can safely do the thing right and so here we're being asked to prioritize after diagnosing with heart failure and getting our lab results that show a low sodium, low normal potassium, and an elevated BNP. So we need to consider which of these orders should the nurse prioritize. And before we talk about this question, let's talk about prioritization. How many of you came to Dr. Amber's lecture on prioritization a couple weeks ago? Because it seems like a couple of you guys have been coming back for these. And we'd love when you... join us each week tune in for these webinars be sure in the group before you guys leave today to invite your friends so that they can also come see Shan you missed it I'm sorry a friend didn't invite you Sabrina came good so yes we want to make sure that you guys are all invited and getting notified when we're having these so please invite your friend to the groups we're really loving the community that you guys are creating here. So from her prioritization lecture, just to give you a quick little recap, obviously first we're going to eliminate any stable chronic issues because those are expected abnormals and not our priority. And then from there, we're going to prioritize first issues of airway and safety. The NCLEX is never going to ask you to prioritize between an airway and a safety issue. That would be too hard. So airway or safety. And then from there, your issues of breathing, circulation, or disability, which is neuros. symptoms maybe like things that would make you worry for hypoglycemia or a mental status change or stroke and then of course everything else routine is our lowest priority so here which of these orders should we prioritize for this client with heart failure either preparing for a chest x-ray giving a nalapril giving furosemide or preparing for an echo what do you guys think take a look at I think a couple of you already said Okay, a couple of you already said you think three. AK thinks it's three. All right. So I'm going to ask you guys, do you remember the kind of NCLEX strategy of always assessing first? How many of you guys have heard that before? In a priority question, you always want to pick the one that's assessment first. I know you've heard that. That's so common, right? And here I'm going to point out we've got two assessment actions. We've got prepare for chest x-ray, prepare for echocardiogram. Those are forms of assessment. But do we need a chest x-ray or an echocardiogram to know that this patient has trouble breathing and fluid overload? No. Sometimes additional assessment is not necessary, and this is one of those cases. So you've got to know the content. You can't get caught up in just test-taking tips, right? So between our meds, enalapril and furosemide, those of you who said furosemide, you want to do that one first. Why is that? The one. one that you'd pick over enalapril because furosemide is what what class of medication is this that is it's a loop diuretic so we want to make sure that we get that fluid off that fluid that pulmonary edema is what's creating all of these issues breathing so we want to do that first exactly good you guys are doing great excellent so next we want to know finally did it help we want to evaluate was it effective whether that was our intervention or our teaching? Was our teaching effective? Or maybe what signs would tell us a complication has developed? So let's look at that here. We have been, we're being discharged on enalapril, metoprolol, furosemide. We've taught the client and we need to figure out which statements indicate the teaching was effective. And because this is a select all that apply, we're going to treat each option like its own true or false. Okay. So true or false that this indicates teaching was effective. It's best if I take my furosemide first thing in the morning wake up true or false what do you guys think so you might have heard the sort of pneumonic for furosemide which is Lasix that it lasts six so it's got a duration of action of about six hours that means if you give that furosemide at night before bed your patient is going to be all night peeing and you are never gonna get to sit down at the nurse's station no this needs to be given in the morning so that it does not interfere with their sleep so this is effective teaching good I should avoid eating prepackaged foods and over seasoning my food with salt is that true or false? So yes, got a couple of trues. Very good because a lot of patients think that it's sufficient just to take the salt shaker off the table, but actually most of the sodium that we eat comes from packaged, canned, boxed foods. So that is true. We want to tell them to avoid prepackaged foods. Then I should contact my healthcare provider if I gain more than three to five pounds or 2.3 kilos in a week. Is that true or false? Yes, Catherine says yes. I agree because you can't really gain fat that quickly if you have weight gain that rapid in a heart failure patient. That tells you that they are going into fluid overload and they're at risk for decompensation and being admitted to the hospital. How about this next one? It is important to weigh myself weekly to ensure that I'm not retaining too much fluid. Is that true or false? Should patients with heart failure weigh themselves weekly? How often should heart failure patients weigh themselves? It's daily, right? Because if we only weigh once a week, it could be too late. This can happen very fast. David, you said here where sodium goes, so does water. That's very true. All it takes is a couple days of eating too much. ...and non-compliance to cause a lot of fluid overload. We don't want to weigh weekly. Jackie's correct. That has to be daily weights. And they even have these fancy scales now that like communicate with an app on your phone or communicate with your healthcare provider's office so they can see your... trends of weight. So yes, we want to wear ourselves every morning, first thing in the morning, after using the bathroom, with no clothes on, or you know, wearing the same clothes, on the same scale, same time, right? So weekly is not enough. This is not correct. Then certain over-the-counter medications, and this might be cut off for y'all, like antacids, can contain high amounts of sodium. Is that true or false? Yeah, that's true. Medications, especially antacids, are really problematic. You think the NCLEX is going to test you only about these really dangerous medications, but a lot of people take antacids and don't realize that they've got a lot of magnesium in them, which is bad for kidney issues. or a lot of sodium in them, which is bad for heart failure and hypertension. So this is correct as well, and we're correct. So well done, you guys. I think you did a great job. Please check us out here on our socials. Remember to invite your friends. But I want to take a second and answer any questions that you guys might have. And hopefully you found this helpful. So what questions might you guys have about everything we covered here today? Of course, Amber is going to be dropping any important links for you. You guys can go check out our study schedule. You can go watch case walkthroughs like this on our other 49 cases. It's not just me, but our other experts in different subject areas, so pediatrics, psychiatry. pediatric, maternal, and so on. So good. Okay, so Kierce wants to know what's a good percentage to be at for NCLEX. So the NCLEX doesn't quite work like other tests where you need to aim for a certain percentage of questions correctly. You really only... need to demonstrate that you're above the passing level so theoretically you could miss up to 50% of the questions on the NCLEX and still pass but if you are using NCLEX bootcamp to study our NCLEX target is 61% and you can see that on your performance page so and I'll show you guys what that looks like so if you're using NCLEX bootcamp to study then you will actually be able to view your performance page here and if you meet these two targets so you answer at least 1238 of our questions and score 61% or higher, you will go on to have a 99% chance of passing the NCLEX. So that's a good goal to start with, for a percentage to be at NCLEX. Sabrina, I'm so glad you found our rationales are awesome. So another prioritization question. Shan, we're going to be repeating our webinars every two months or so. We're going to keep them on a two-month circuit. So keep coming back and keep inviting your friends, please, to join us here so that we can all study together. So, Ramya, I'm so glad that you enjoy boot camp. Brian, we're going to have some farm sessions coming up.

We'll take just a second longer to let some more people show up and then we're gonna get started. Couldn't have done it without this program. Well you're very welcome.

We're very very happy to help. We're so excited that all of you are here. We love helping students pass the NCLEX and yeah hopefully you know you're gonna go on to be a better nurse because of it.

Perhaps some Ron. I hope I'm not saying your name wrong. Thank you.

We love our rationales too and thanks for joining Very good. So, okay. We're gonna go ahead and get started quickly If you guys see me looking off the side of the screen here, I'm watching your comments separately So yes, I am Dr. Emily.

I'm one of the co-creators here at NCLEX Boot Camp. We've got Dr. Amber in the chat moderating, gonna be answering your questions. I'm gonna be watching your comments as well.

There might be a little bit of a delay. We're not ignoring you. We're gonna try and get to everybody's questions by the end of the thing. But yes, thank you so much for joining us. We're so so happy that you're here and we're gonna be talking about answering next-gen case studies.

So first we're gonna look at the NGN case studies. study format, what it looks like, and then most of our time we're going to spend practicing going through a case together so that you guys can get that practice thinking like a nurse, which is really what we want to teach you here at NCLEX Bootcamp. So first, the case study format.

So each case study on the NCLEX is going to have six questions that corresponds to each of these six steps of the clinical judgment measurement model. And you might not be familiar with this, but you've probably seen the nursing process before. your ADPIE and this is really similar this is essentially just the thought processes that we go through in every single patient encounter and so that starts with recognizing cues or assessing out of everything that's going on what's most important here analyzing those cues or considering what could it mean or what disease processes or diagnoses is that associated with prioritizing hypotheses so figuring out what we start with first generating or planning what what solutions or interventions we can take to address those problems, then actually taking those actions and evaluating if they helped.

So we'll go through each of these steps in detail as we answer the case together, but this is ultimately how the case is laid out. And you are gonna have three full-length case studies on a 85-question test. That means it's gonna make up for three cases, six questions each, about 25% of your score. If you have have a longer test than 85 questions, you're gonna see additional clinical judgment items in the form of trend and bow tie items. So, but either way, this is gonna make up a big chunk of your test because this is really important.

This is kind of the heart of nursing. The NCLEX is a safety exam, that is true, but it is also a clinical judgment exam starting with NextGen where we need to make sure that we can think like nurses to keep our patients safe. So we'll get some practice doing that together.

So let's do it. Let's practice thinking like a nurse. And we're going to be walking through one of our cases together.

And I want to know from you guys, how many of you were actually able to practice next-gen cases in school? Like in your nursing program, let me know if you had some kind of school-provided next-gen case study practice or if you had to go somewhere else to practice next-gen cases. I think it's really hard to create these really well and so we've got 50 case studies on our website for you to practice with.

So Keir said not me, neither did Verona, so yeah it's... it's really kind of hard to come by good solid next-gen case study practice. So we're going to walk through this case today, but yeah, we've got 49 others on our website that you guys should definitely check out. And Amber's going to make sure the link to our stuff is down there for you.

But yeah, this is basically what it looks like. The big difference in the next-gen cases versus your standalone NCLEX items is you've got a lot more information. You guys might have heard that the NCLEX is vague and that is true for the standalone items. You only really have enough information to answer the question, but that's not real life. In real practice, our patients never have just one problem in isolation.

They never have just pneumonia, right? They have so many different things going on. Their chart is full of information and we want to make sure as the first step that we can get the right information out there. that we can recognize cues or figure out what's most important here.

So in the case, you'll be able to click through all your tabs just like you would in a real patient chart. And that when you are recognizing these cues, reading through these client data tabs, I want you guys to really practice every single time envisioning this scenario closely. Try and Keep this mental picture in your mind of what's going on with the patient and always kind of have in mind what you think your priority problem or priority problems are.

So don't lose sight of that, try and keep that in mind as you progress through the case. course at any point if the case client data tabs update or you get new information revisit that mental picture there are things that can happen in these case study updates you can move from the ER to the OR or from the ICU to step down or even be discharged home. And so make sure you have this mental picture of what's happening with the patient at each step in the case. So let's take a second envisioning this scenario closely. I'm gonna kinda click through and highlight important things.

Of course, on the real exam, you guys are gonna have a whiteboard that you can use to kind of note anything that you think is really important to keep in mind. All right, so keep all this in mind. We've got this 57-year-old client.

He comes to the emergency department feeling short of breath and having a cough for the last few days. He's been sleeping on two pillows, waking up coughing. He's felt very fatigued and spends most of the day in the bed or the chair.

He appears anxious and then he has got this long history of cardiovascular risk factors, hypertension, hyperlipidemia, chronic stable angina, type 2 diabetes, and he's worried that he can't afford his medications. So reminding you guys to keep this mental picture in mind as we move on. This relatively young gentleman is short of breath, he's coughing, he's anxious about it, he's sitting upright. Keep that mental picture in mind and add to it as we continue reading, alright?

So in our assessment we see he's oriented, that's good. He's got crackles in his lungs, he has an S1, S2 and an extra S3 heart sound. His bowel sounds, cap refill and pulses are all normal and then he's got one plus pitting edema to his lower lower extremities.

So on top of this picture of shortness of breath, staying upright, he's also got edema and extra heart sound and crackles. Keep all this in mind. Then we look at our vitals. We see that he's afebrile. He's a little tachycardic, little tachypneic, little hypertensive, and then our pulse oximetry reading is low.

So keep all this mental picture. And I want to ask you guys, I kind of see two priority problems here, two big things that are happening. what would you guys say your priority problem is?

Drop it in the chat what you think is kind of the priority thing that's going on. Because I think there are two, and I think we all see the first one is maybe the shortness of breath, right? He can't breathe.

We don't need to overcomplicate it. He can't breathe. He's having a hard time breathing. We've got the dyspnea, the low pulse oximetry. What might your other problem be, your second priority problem?

So in addition to these respiratory problems, findings what other things are you guys seeing here what are the problem Yes, Jackie, the shortness of breath. Definitely that respiratory insufficiency is, I think, a big one. Shan says the crackles, definitely. So yeah, we've got these other signs that really make it seem like maybe he has too much fluid on him, right? We've got swollen lower extremities.

The extra heart sound, the S3, is always going to indicate fluid overload, right? So we've got somebody who's short of breath with some fluid overload. So keep this mental picture and those two priority problems in mind.

So, all right. Now we want to consider what's most important here. You saw there was a lot happening, but there are only a couple of things that are most important.

And the NCLEX might ask you that as what requires immediate follow-up or which two, three, or four findings are most concerning. So as we consider that, try and figure out what are our unexpected abnormals that we're looking for. And if you're being asked about how to follow up and you're not sure, always kind of have in mind how you... you would follow up? What would it look like if I was going to select this option and follow up on that?

So let's keep that in mind. So of these findings, we want to select the top four that require immediate follow-up. So we're looking for unexpected abnormals that we can do something about.

And keep in mind that for a select N, so if you're told to select two, select three, select four, you always want to select the maximum number possible because you won't lose points for selecting an extra option, if that makes sense. So in a regular SATA only select the ones you're sure of if you're being asked to select a certain number always select that Full number never leave one off All right So let's go through and we're only going to select at first the ones that we are 100% sure Require immediate follow-up and nothing could convince us otherwise. So let's take these One at a time. What do you guys think for cough? Do you think that we need to immediately follow up on the cough?

Yes or no? Is that something that requires immediate follow-up? So when I think, is this an issue of airway, breathing, circulation, it might be related to a respiratory problem, right? Maybe an upper respiratory tract infection, but Shan, I...

with you. Shan says no and I agree. We really don't want to follow up on that cough right now. There's nothing that I would do about this right now. So great, the edema.

So what do you guys think? Is the edema something that I want to follow up on immediately? Because it is potentially an issue of circulation, right? But, okay, Shan thinks yes.

I'm not so sure because if I know that one of my issues is he's having trouble breathing, breathing, he can't breathe, I'm probably going to hang on for some respiratory findings first. But I'm going to keep this in mind. This might be a good priority issue. Crackles. Okay, Jackie says crackles.

Yes, I agree with you. So yes. when you hear crackles that means something is happening in the lung that's interfering with gas exchange and we have evidence of that right we've got a low pulse oximetry reading so these crackles tell me something's happening that's impairing his respiratory status good how about the respirations do you guys want to address those immediately yes Mariana Courtney says yes I agree that tachypnea is compensatory right if you've got a low pulse oximetry which hypoxemia is our next option here then your body's gonna compensate by increasing that respiratory rate to try and get more oxygen delivered into your lungs because it's not picking up enough and carrying enough good all right so we've got three so far is blood pressure our fourth what do you guys think do we need to immediately follow up on this blood pressure So Shan says, no, Shan, you're killing it today with these. I agree with you.

So I'll ask you this about the blood pressure. Is it expected or unexpected for this client? This blood pressure of 149 over 93, expected or unexpected?

So I'm gonna point out here this guy's got a history of hypertension, right? So he not only has high blood pressure, but he's also told us that he's been concerned about affording his medications Maybe he hasn't been taking them. So this might just be his everyday blood pressure.

Yes, I agree with you guys. I think this is expected. If he had some unexpected signs of high blood pressure, like a really severe headache or blurred vision or mental status changes, then I might prioritize.

that but he doesn't I think this is expected and we can ignore it good shortness of breath what do y'all think I think you guys I think you guys know what to do with this one should we follow up on the shortness of breath and yes definitely so that is part of our big picture respiratory insufficiency but let's consider our last two options just to be sure how about his inability to afford medications well there's nothing really I can do even though it is obviously very important that we get our patients access to their medications and their care. That's not something I'm gonna immediately follow up on as a psychosocial issue. I'm not gonna call a social worker in here while he is sitting up breathing hard fast with a low pulse oximetry. Same thing with the history of chronic stable angina. How would I follow up on that?

Just like ask him things about his history, how well it's controlled. There's really nothing for me to do about this. It is gonna help us inform what might be causing his symptoms but it is not higher priority than these.

these signs of respiratory insufficiency are crackles, tachypnea, hypoxemia, and shortness of breath. And we're correct, well done you guys. So average score on this was only one out of these four.

So you guys who got all four are way ahead of the curve, well done. All right, so our next question in CJM cases is going to be analyzing cues, or then figuring out what could it mean? And the NCLEX might ask you what conditions are the clients experiencing or at risk for experiencing?

experiencing, what disease processes could cause these findings we're seeing, or how would you know if X or Y disease was happening? So keep in mind the big picture. We've considered in the previous questions the individual findings. Now you want to think about the big picture and specifically consider some specific versus non-specific findings.

And shortness of breath is a very common non-specific finding. It could mean a hundred different things. So I want you guys to drop in the chat. What are anything that you can think of that would cause?

Shortness of breath because there's just so many things I'll start naming a couple with you. I think we have the obvious. If we start ABCs, we could have any kind of airway issue, right?

Maybe smoke inhalation or in a child, like an epiglottitis, breathing. so Shan says asthma definitely Miriam says COPD for sure these can cause breathing issues maybe pneumonia yep Brianna got it pneumonia how about some circulation issues are there any circulation issues that can cause short breath shortness of breath. Okay. AK says CHF. Yes.

Cardiac problems, Mariana. Very good. What about something like anemia, right?

We don't have enough oxygen carrying capacity in our blood. Maybe a pulmonary embolism. We can't get blood flow to the lungs.

So you can kind of see there are so many different things that can cause shortness of breath, and it's not a very specific finding. But then we do have some specific findings that might be associated with it. So for example, think Think about a patient who has shortness of breath and we think it's pneumonia.

What other signs and symptoms that that patient had might make us think it's pneumonia? Like what other findings apart from the shortness of breath would point you toward pneumonia? Think like vital signs, lab values, symptoms.

What are some specific findings? Fever, definitely. AK's got it.

Yeah. Fever, white blood cell count might be elevated. Maybe they've got a...

productive cough, so they're coughing up yellow-green sputum. So if our nonspecific finding is shortness of breath, our specific finding might be the fever, the sputum, the white blood cell count. So we wanna consider the big picture here as we go in to analyze these cues.

And we need to figure out that crackles throughout the lungs in this client are due to either infective infiltrate, collapsed alveoli, or fluid accumulation related to either pneumonia, heart failure, or reduced mobility. So crackles is what we're thinking about here. And any of these things could cause crackles, right?

Have you guys had an opportunity to actually listen and auscultate crackles in your clinical sites? Or maybe if you're already working somewhere? chance to hear this before.

Sounds kind of cool. It's described as like that snap crackle pop sound and if you've never heard this in your patient you can actually just take, so Shan hasn't heard it, you can grab a little piece of your hair and kind of roll it back and forth between your fingers and it creates that kind of snap crackle pop noise and that's what crackles sound like. And so this is described to me as, think of it like you're blowing bubbles through a straw is what you're hearing.

You're hearing air passing through fluid or if alveoli you'll like collapse, they can kind of pop open in the inspiration. So any of these things can cause crackles. And in this client, do you guys think that these crackles are due to an infective infiltrate, yes or no?

So infective infiltrate is just a fancy word for pus, right? If we've got pus, infectious material in the lung, obstructing the airflow, which condition would infective infiltrate be related to, you think? Pneumonia, heart failure. or reduce mobility good you guys are saying no I agree I don't think so either so of these conditions we talked about pneumonia being the infectious one right so I don't think it's that in this client I agree with you guys now how about collapsed alveoli which of these conditions would cause alveoli to collapse Pneumonia might cause the alveoli to collapse, but you guys remember after a patient has surgery or when they're really immobile For example, this guy's been spending most of the day in the bed or the chair.

They can start to have atelectasis. So although he's at risk for this if you're ever here if you ever hear crackles if you ever hear that snap crackle pop in your patient's lungs you can ask them to cough and that's gonna clear those so if you're if your crackles clear with coughing say that three times fast then you know that they were probably due to atelectasis. And this guy's been coughing for two days, he's been coughing all night.

So I would have expected these crackles to clear if they were due to atelectasis. So then that leaves us with fluid accumulation, which you guys all, I think, want to pick and have pointed out that's related to heart failure. So how would crackles cause, or how would fluid accumulation cause crackles in heart failure?

Let's talk about that. So in heart failure, there are two major risk factors that would strain your heart muscle so the two big ones are high blood pressure, which our client has and coronary artery disease a lack of blood flow to the Heart so if you have high blood pressure that hearts gonna have to work harder to pump if you have a lack of blood flow To the heart. It's not getting enough oxygen supplied to it to pump So those result in this ventricular dysfunction where the heart doesn't have enough squeeze It can't squeeze blood forward and so instead that fluid can back up into your lungs Filling the alveoli and cause that blowing bubbles through straw kind of sound when you listen to it So yes, I think that that is our correct answer and we're correct well done again only about half people got this so you guys are doing a great job so next after analyzing cues we want to prioritize hypotheses or consider where do I start and the NCLEX for this might ask you what is the client most likely experiencing what are they at highest risk for or what do you need to do first and when we're talking about prioritizing I always like to kind of keep this question in the back of my mind of if I can only do one thing for my patient and walk away, what should that one thing be?

All right, so we are gonna prioritize hypotheses here and we're being asked about risk. So this client is at highest risk for developing either respiratory failure, acute kidney injury, sepsis, or pulmonary embolism, and we can pick two. So our two biggest risk factors. What do you guys think might be one of them?

I think as we start top to bottom, do you think this client is at risk for respiratory failure and that that's gonna be one of our two? highest risks. So yeah, Shan says yes and I agree. Remember that was our number one priority issue we identified from the beginning and we want to keep that picture in mind. This guy can't breathe.

Of course we're worried about respiratory failure. He's got low pulse oximetry. He's hypoxemic. I'm definitely worried about that. How about acute kidney injury?

How would heart failure cause acute kidney injury? Okay, you guys are saying yes. Alright, so let's think about this. Acute kidney injury is a form of organ failure, right? And whenever you've got this ventricular dysfunction, not only is that blood not being pumped forward and back.

up into the lungs but because it's not being pumped forward it's not reaching the organs either as well and so your kidneys depend on 25% of your cardiac output every milliliter of blood that leaves your heart 25% of those go to the kidneys And so your kidneys are gonna be affected first if you have a decrease in cardiac output and you can start to have this reduced end organ perfusion and organ failure. So definitely I'm worried about acute kidney injury. I don't know if it's one of my top two yet though.

So let's put a pin in that. So sepsis, what kinds of things put clients at risk for sepsis? What condition would put this guy at risk for sepsis?

So if sepsis is an infection of the bloodstream, right, you would have to have an infection somewhere else first. So maybe a pneumonia or some other infection. We've already pointed out we don't have any evidence of infection. We don't have a fever. We don't have purulent sputum.

this is unlikely. How about a PE? I think I saw somebody say that at some point. What puts someone at risk for a PE?

What other disease process? Because a PE starts usually where? In the legs, right? Good.

Very good. So for sure. I don't think he has a PE or a DVT right now because we only have, we have pitting edema in both lower extremities. If we had it in just one lower extremity, that might make us think he has a DVT, which would be a risk for a PE.

So although he is at risk for all of these things, he's been immobile, so he's at risk for a DVT. He obviously is hospitalized or going to be. so he's at risk for infection just because we're touching him. But of the ones that we saw, yes, the respiratory failure and the acute kidney injury or really any form of organ failure are the two big ones.

And we are correct, well done. So all right, next. Our next step is gonna be generating solutions or after identifying this priority problem, we need to figure out what can I do about it?

So the NCLEX might ask which interventions are indicated or not indicated, which are gonna address that priority problem or which could work. worsen the priority problem. And so I wanna point out here that this depends on your understanding of the content, because the same symptom we could treat two different ways if it's from two different disease processes.

So how would you guys treat shortness of breath from pneumonia? What medication would you give? So to treat any sort of infection, we would need to give antibiotics, right? versus shortness of breath from a pulmonary embolism.

What medication would you give for that? Okay, Jackie says furosemide might be, all right, albuterol, so yeah. The furosemide for fluid, albuterol for bronchoconstriction.

I was thinking antibiotics for pneumonia or heparin for a PE, right? So same symptom, four different treatments. So you guys gotta understand the content and that's why we're talking about heart failure in detail.

So now that we need to actually generate solutions, let's consider each one of these. Do we need to get blood for a blood culture? Is there any reason that we have to want to get a blood culture for this guy?

So that would be indicated for someone who we do think has an infection, right? If they have the fever, if they have the purulent sputum, same thing sputum for culture. We don't even know that his cough is productive. That is not anticipated.

So I'm not going to select these. Then preparing for an echocardiogram. Does this gentleman need an echocardiogram?

What do you guys think? What do you think about if he should get an echo? Okay, I can't tell if our no's are from the previous option or not, but Shan says yes. Shan, you should come to our webinars every week.

But yes, I definitely want to get an echo, because in an echo, they're able to actually visualize the heart. They do this at the bedside, and we can see. how much blood is being pumped out of the heart with each beat and that tells us about the cardiac output and heart failure is a problem of cardiac output so I definitely want to do the echo.

What about serum renal function tests? Do we need to do those? Sabrina says yes. Carmel says yes.

Yes, not only do we want to check for the acute kidney injury that we're worried about, but we also might be giving a medication that we need to check the renal function for. What medication do you guys might want to give this guy soon that we need to know his kidneys are functioning for first before we give it? This is a big NCLEX test thing, so make sure you know this. What medication would we want to look at his renal function for?

It's gonna be the Lasix, right? The furosemide. Our loop diuretics are nephrotoxic, so we don't want to give him the loop diuretic until we know that his kidneys can tolerate it and that he's not in renal failure.

So I definitely want to do this. Oxygen. Does he need oxygen? Yes, I think you guys know that.

If his pulse oximetry reading is under 90%, he needs oxygen. So we are going to give him some oxygen to titrate to keep his pulse ox greater than 90 to 94%. Do we need to get a 12 lead ECG?

We need to hook some stickers up to this guy and see what his heart rhythm is doing. Okay, you guys are saying yes. Yes, because we don't know if his heart failure could be caused by maybe a heart attack or atrial fibrillation.

He does have all of the risk factors for a myocardial infarction, and myocardial infarction is the number one cause of cardiogenic shock, which is an extreme form of heart failure. So definitely I want to get a 12-lead EKG and make sure his heart is not... not failing because the muscle is dying basically then draw serum b-type natriuretic peptide do we need to get this do we need to get a b-type yes Michelle says yes for sure because the B in P is released when your ventricles stretch so if we have a high B and P in the blood that tells us that those ventricles are being stretched from fluid overload it tells us about the severity of heart failure so yes these are the things I want to do for this guy right now get him some oxygen and then do a quick workup with an echo to visualize his cardiac output make sure his kidneys are doing okay before we give him any Lasix get the 12 ad kg make sure he's not having an MI and then get the BNP to diagnose the severity of the heart failure and we're correct very good alright so next we need to look at taking action or what will I do should I do it how do I do it the NCLEX wants to know that you can safely do the thing right and so here we're being asked to prioritize after diagnosing with heart failure and getting our lab results that show a low sodium, low normal potassium, and an elevated BNP. So we need to consider which of these orders should the nurse prioritize.

And before we talk about this question, let's talk about prioritization. How many of you came to Dr. Amber's lecture on prioritization a couple weeks ago? Because it seems like a couple of you guys have been coming back for these. And we'd love when you...

join us each week tune in for these webinars be sure in the group before you guys leave today to invite your friends so that they can also come see Shan you missed it I'm sorry a friend didn't invite you Sabrina came good so yes we want to make sure that you guys are all invited and getting notified when we're having these so please invite your friend to the groups we're really loving the community that you guys are creating here. So from her prioritization lecture, just to give you a quick little recap, obviously first we're going to eliminate any stable chronic issues because those are expected abnormals and not our priority. And then from there, we're going to prioritize first issues of airway and safety.

The NCLEX is never going to ask you to prioritize between an airway and a safety issue. That would be too hard. So airway or safety.

And then from there, your issues of breathing, circulation, or disability, which is neuros. symptoms maybe like things that would make you worry for hypoglycemia or a mental status change or stroke and then of course everything else routine is our lowest priority so here which of these orders should we prioritize for this client with heart failure either preparing for a chest x-ray giving a nalapril giving furosemide or preparing for an echo what do you guys think take a look at I think a couple of you already said Okay, a couple of you already said you think three. AK thinks it's three. All right.

So I'm going to ask you guys, do you remember the kind of NCLEX strategy of always assessing first? How many of you guys have heard that before? In a priority question, you always want to pick the one that's assessment first. I know you've heard that. That's so common, right?

And here I'm going to point out we've got two assessment actions. We've got prepare for chest x-ray, prepare for echocardiogram. Those are forms of assessment. But do we need a chest x-ray or an echocardiogram to know that this patient has trouble breathing and fluid overload? No.

Sometimes additional assessment is not necessary, and this is one of those cases. So you've got to know the content. You can't get caught up in just test-taking tips, right?

So between our meds, enalapril and furosemide, those of you who said furosemide, you want to do that one first. Why is that? The one.

one that you'd pick over enalapril because furosemide is what what class of medication is this that is it's a loop diuretic so we want to make sure that we get that fluid off that fluid that pulmonary edema is what's creating all of these issues breathing so we want to do that first exactly good you guys are doing great excellent so next we want to know finally did it help we want to evaluate was it effective whether that was our intervention or our teaching? Was our teaching effective? Or maybe what signs would tell us a complication has developed?

So let's look at that here. We have been, we're being discharged on enalapril, metoprolol, furosemide. We've taught the client and we need to figure out which statements indicate the teaching was effective.

And because this is a select all that apply, we're going to treat each option like its own true or false. Okay. So true or false that this indicates teaching was effective.

It's best if I take my furosemide first thing in the morning wake up true or false what do you guys think so you might have heard the sort of pneumonic for furosemide which is Lasix that it lasts six so it's got a duration of action of about six hours that means if you give that furosemide at night before bed your patient is going to be all night peeing and you are never gonna get to sit down at the nurse's station no this needs to be given in the morning so that it does not interfere with their sleep so this is effective teaching good I should avoid eating prepackaged foods and over seasoning my food with salt is that true or false? So yes, got a couple of trues. Very good because a lot of patients think that it's sufficient just to take the salt shaker off the table, but actually most of the sodium that we eat comes from packaged, canned, boxed foods.

So that is true. We want to tell them to avoid prepackaged foods. Then I should contact my healthcare provider if I gain more than three to five pounds or 2.3 kilos in a week.

Is that true or false? Yes, Catherine says yes. I agree because you can't really gain fat that quickly if you have weight gain that rapid in a heart failure patient.

That tells you that they are going into fluid overload and they're at risk for decompensation and being admitted to the hospital. How about this next one? It is important to weigh myself weekly to ensure that I'm not retaining too much fluid.

Is that true or false? Should patients with heart failure weigh themselves weekly? How often should heart failure patients weigh themselves? It's daily, right?

Because if we only weigh once a week, it could be too late. This can happen very fast. David, you said here where sodium goes, so does water. That's very true. All it takes is a couple days of eating too much.

...and non-compliance to cause a lot of fluid overload. We don't want to weigh weekly. Jackie's correct.

That has to be daily weights. And they even have these fancy scales now that like communicate with an app on your phone or communicate with your healthcare provider's office so they can see your... trends of weight.

So yes, we want to wear ourselves every morning, first thing in the morning, after using the bathroom, with no clothes on, or you know, wearing the same clothes, on the same scale, same time, right? So weekly is not enough. This is not correct. Then certain over-the-counter medications, and this might be cut off for y'all, like antacids, can contain high amounts of sodium. Is that true or false?

Yeah, that's true. Medications, especially antacids, are really problematic. You think the NCLEX is going to test you only about these really dangerous medications, but a lot of people take antacids and don't realize that they've got a lot of magnesium in them, which is bad for kidney issues.

or a lot of sodium in them, which is bad for heart failure and hypertension. So this is correct as well, and we're correct. So well done, you guys. I think you did a great job. Please check us out here on our socials.

Remember to invite your friends. But I want to take a second and answer any questions that you guys might have. And hopefully you found this helpful.

So what questions might you guys have about everything we covered here today? Of course, Amber is going to be dropping any important links for you. You guys can go check out our study schedule.

You can go watch case walkthroughs like this on our other 49 cases. It's not just me, but our other experts in different subject areas, so pediatrics, psychiatry. pediatric, maternal, and so on.

So good. Okay, so Kierce wants to know what's a good percentage to be at for NCLEX. So the NCLEX doesn't quite work like other tests where you need to aim for a certain percentage of questions correctly.

You really only... need to demonstrate that you're above the passing level so theoretically you could miss up to 50% of the questions on the NCLEX and still pass but if you are using NCLEX bootcamp to study our NCLEX target is 61% and you can see that on your performance page so and I'll show you guys what that looks like so if you're using NCLEX bootcamp to study then you will actually be able to view your performance page here and if you meet these two targets so you answer at least 1238 of our questions and score 61% or higher, you will go on to have a 99% chance of passing the NCLEX. So that's a good goal to start with, for a percentage to be at NCLEX. Sabrina, I'm so glad you found our rationales are awesome. So another prioritization question.

Shan, we're going to be repeating our webinars every two months or so. We're going to keep them on a two-month circuit. So keep coming back and keep inviting your friends, please, to join us here so that we can all study together. So, Ramya, I'm so glad that you enjoy boot camp.

Brian, we're going to have some farm sessions coming up.

Transcript for:NCLEX Bootcamp Case Study Overview

Transcript for:
NCLEX Bootcamp Case Study Overview