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THE BEST NURSING CONCEPTS FOR CLINICAL JUDGMENT & NEXT GEN NCLEX

Jun 27, 2022, 14:14 PM
<13-min. read> If you want to expand the nursing frameworks you use in teaching clinical judgment, we define the 6 most common, along with item samples and rationales.

CLINICAL JUDGMENT: THE TOP 6 PRIORITY-SETTING FRAMEWORKS WHEN PREPARING FOR THE NEXT GEN NCLEX

As you begin preparing students for the Next Generation NCLEX (NGN), strengthening their clinical judgment skills will become a fundamental aspect of your teaching (if it’s not already). A nursing concept that is directly related to the development of clinical decision-making and judgment is priority setting.


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Priority-setting questions Next Gen NCLEX expert Sheryl Sommer

Priority setting has become more important over the last couple of decades as healthcare has evolved. Sheryl Sommer, PHD, RN, CNE, former Vice President and Chief Nursing Officer at ATI, explained. “Nurses today have a much higher level of demand on their services,” she said. “That demand means they must ration the care they give. In other words, they must determine the priority of care that clients require as conditions change and needs arise.”

If the term priority setting doesn’t sound familiar, don’t worry. You’ve been teaching the technique, even if you haven’t been using that verbiage. Basically, priority setting is when you look at nursing problems in terms of urgency and/or importance to determine which ones to deal with first.

CLINICAL JUDGMENT & YOUR CHOICE OF PRIORITY FRAMEWORKS FOR NEXT GEN NCLEX

As nurse educators have reviewed lesson plans and curriculum in anticipation of the Next Gen NCLEX, discussions have been common regarding which framework — or process — is the best to use. (One misunderstanding that the National Council of State Boards of Nursing wants to dispel is that you will need to change the nursing framework you use. Dr. Sommer explained why this isn’t the case and how similar the most prominent frameworks are to one another in an article she wrote for Nurse Educator journal.)

You have a variety of priority-setting frameworks from which to choose in teaching your students, and chances are you’ve already been using one — or several — of them in your lessons. (Scroll down for details on the most common ones.)


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Why is it important to teach students about these frameworks? First, you’ll help them learn to order their thinking and, therefore, advance their clinical judgment. Second, you’ll help prepare for the Next Gen NCLEX. Admittedly, students and new nurses may not immediately identify which framework they are using as they assess client priorities. In essence, these frameworks will become an inherent part of their processing, and they will automatically pick and choose among them to use the cognitive functions that best match the situation.

PREPARING FOR NEXT GEN NCLEX WITH THE 6 MOST-COMMON PRIORITY-SETTING FRAMEWORKS FOR CLINICAL JUDGMENT

To help you in teaching these frameworks — in general and in preparation for the Next Gen NCLEX — we’ve broken out the 6 most common. We describe how the process works within each, then provide an item example and rationales for each answer. (We identify the correct answer and matching rationale in red.) Feel free to use these samples in your lessons.

The priority-setting frameworks described here are:

  1. Maslow’s Hierarchy of Needs
  2. The Nursing Process
  3. Airway – Breathing – Circulation
  4. Safety & Risk Reduction
  5. Least Restrictive/Least Invasive
  6. Acute vs. Chronic/Unstable vs. Stable/Urgent vs. Nonurgent.

PUTTING NURSING FRAMEWORKS INTO ACTION WITH STRATEGIES FOR NEXT GEN NCLEX PREP

As you review each of these frameworks, consider the following strategies to help students improve their skills in prioritizing care:

  • Use priority-setting NCLEX items as tools in the classroom or clinical post conference.
  • Assign screen-based simulations or videos with clinical scenarios that require students to respond based on a particular priority-setting framework.
  • Use priority-setting frameworks in classroom activities, such as case studies.

Some priority-setting questions you can use are:

  • Which of the following actions should the nurse initiate first?
  • Which of the following assessment findings should the nurse report to the provider immediately?
  • Which of the following clients should the nurse assess first?
  • Which of the following is the next action the nurse should take?

MASLOW'S HIERARCHY OF NEEDS: OPTION 1 FOR TEACHING CLINICAL JUDGMENT

Maslow's Hierarchy of NeedsThis framework contains 5 levels of prioritized needs. (See diagram at right.) Physiological needs supersede the others in most circumstances. However, all client factors should be considered before determining need order.

ITEM EXAMPLE

A nurse is planning care for a client who has bipolar disorder and is experiencing an acute manic episode. Which of the following is the highest priority intervention the nurse should include in the plan of care?

A. Give the client simple directions for completing ADLs.

B. Offer the client high-calorie fluids frequently.

C. Provide the client with structured solitary activities.

D. Keep the client’s valuables in a locked area.

RATIONALES

A. Clients who are having an acute manic episode are likely to have poor concentration and difficulty completing routine tasks. Providing simple directions for completing ADLs helps the client focus; however, the nurse should take another action first.

B. The priority action for a client who is experiencing an acute manic episode is to meet the client’s physiological need for food and water. Therefore, the priority intervention is to offer the client high-calorie fluids frequently to prevent calorie deprivation and dehydration.

C. Clients who are having an acute manic episode are likely to have difficulty focusing on any one activity. Providing the client with structured solitary activities helps provide focus and feelings of security; however, the nurse should take another action first.

D. Clients who are having an acute manic episode are likely to give away their valuables. Keeping the client’s valuables in a locked area prevents the client from doing so; however, the nurse should take another action first.

AIRWAY – BREATHING – CIRCULATION: OPTION 2 FOR TEACHING CLINICAL JUDGMENT

Airway-Breathing-CirculationOften called the ABCs, this framework is always the priority for initial assessments when the client's life is at stake as all 3 attributes are essential for survival.

ITEM EXAMPLE

A nurse is caring for a client who is wheezing and gasping for breath just after receiving a dose of amoxicillin. Which of the following actions is the nurse’s priority?

A. Administer epinephrine parentally.

B. Provide reassurance to the client.

C. Initiate an IV infusion of 0.9% sodium chloride.

D. Place client on a cardiac monitor.

RATIONALES

A. The nurse’s priority is to give the client an injection of epinephrine, which will counteract the bronchoconstriction.

B. The nurse should reduce the client’s anxiety by providing reassurance; however, the nurse should perform another action first.

C. Starting an IV infusion of 0.9% sodium chloride is important to maintain fluid balance and provide venous access; however, the nurse should perform another action first.

D. Attaching the client to a cardiac monitor is important, because medications used to treat anaphylaxis can cause tachycardia and dysrhythmias; however, the nurse should perform another action first.

SAFETY & RISK REDUCTION: OPTION 3 FOR TEACHING CLINICAL JUDGMENT

Safety and Risk ReductionThis framework establishes priority based on which situation poses the greatest threat to the client at that time. When multiple risks are present, another priority-setting framework, like the ABCs, may need to be used to identify the highest priority.

ITEM EXAMPLE

A nurse is planning care for a client who is in acute alcohol withdrawal. Which of the following medications should the nurse plan to administer first?

A. Disulfuram

B. Lorazepam

C. Clonidine

D. Atenolol.

RATIONALES

A. Disulfuram is given to support abstinence from alcohol and prevent relapse; however, this is not the greatest risk to the client at this time.

B. The greatest risk to the client during acute alcohol withdrawal is seizures. Therefore, the nurse should first administer lorazepam to control or minimize seizures.

C. Clonidine can help minimize the autonomic symptoms that occur with acute alcohol withdrawal; however, these are not the greatest risks to the client at this time.

D. Atenolol can help minimize the autonomic symptoms that occur with acute alcohol withdrawal; however, these are not the greatest risks to the client at this time.

THE NURSING PROCESS: OPTION 4 FOR TEACHING CLINICAL JUDGMENT

Nursing process graphicThis framework is a 4- or 5-step process (differing between PNs and RNs) that nurses use for decision-making. It helps determine priority nursing actions based on the steps in the diagram at right and always starts with data collection/assessment.

ITEM EXAMPLE

A nurse is caring for an adolescent who is to undergo an open reduction and internal fixation of the ankle following a sports injury. The client is extremely anxious and having difficulty sleeping. Which of the following is the priority intervention?

A. Provide dim lighting in the client’s room.

B. Allow the client’s family to spend the night with him.

C. Offer music as a distraction.

D. Ask the client to tell you what he knows about the procedure.

RATIONALES

A. Providing dim lighting in the client’s room can promote sleep for some clients; however, the nurse should take a different action to address the client’s anxiety.

B. Allowing the client’s family to stay with him can help reduce his anxiety; however, the nurse should take a different action to address the client’s anxiety.

C. Offering music as a distraction can help reduce his anxiety; however, the nurse should take a different action to address the client’s anxiety.

D. The first action the nurse should take is to assess the client. By determining the client’s understanding of the procedure, the nurse can provide information needed to help decrease the client’s anxiety.

LEAST RESTRICTIVE / LEAST INVASIVE: OPTION 5 FOR TEACHING CLINICAL JUDGMENT

Least Restrictive - Least InvasiveThis framework sets priorities based on the interventions that are the least restrictive or invasive to the client to minimize the risk for harm to the client.

ITEM EXAMPLE

A nurse is caring for a client who gave birth vaginally 8 hours ago. The client reports feeling weak and dizzy. The nurse notes that the client’s perineal pad is soaked with blood. Which of the following actions should the nurse take first?

A. Administer oxygen at 10 L/minute via face mask.

B. Insert an indwelling urinary catheter.

C. Massage the fundus of the uterus.

D. Administer oxytocin 20 units in 1000 mL of lactated ringers.

RATIONALES

A. Manifestations of postpartum hemorrhage include saturation of the perineal pad, as well as dizziness and weakness. The nurse may need to administer oxygen; however, the nurse should perform a less-invasive intervention first.

B. Manifestations of postpartum hemorrhage include saturation of the perineal pad, as well as dizziness and weakness. The nurse may need to insert an indwelling urinary catheter; however, the nurse should perform a less-invasive intervention first.

C. Manifestations of postpartum hemorrhage include saturation of the perineal pad, as well as dizziness and weakness. When providing client care, the nurse should first use the least-invasive intervention; therefore, the first action the nurse should take is to massage the client’s fundus.

D. Manifestations of postpartum hemorrhage include saturation of the perineal pad, as well as dizziness and weakness. The nurse may need to administer oxytocin; however, the nurse should perform a less-invasive intervention first.

ACUTE VS. CHRONIC / UNSTABLE VS. STABLE / URGENT VS. NONURGENT: OPTION 6 FOR TEACHING CLINICAL JUDGMENT

Acute vs ChronicThese 3 subframeworks establish the priority need based on the client condition and may be used when the other frameworks do not apply to the client-care situation.

  • ACUTE VS. CHRONIC

    Addressing acute problems before chronic problems is important because there is a great risk posed for acute problems.

  • UNSTABLE VS. STABLE

    Unstable clients pose a greater threat than stable clients and need to receive care first.

  • URGENT VS. NONURGENT
    Urgent needs pose a greater threat to a client than a nonurgent need.

ACUTE VS. NONACUTE ITEM EXAMPLE

A nurse is receiving a hand-off report at the beginning of the shift for 4 clients. Which of the following clients should the nurse assess first?

A. A client who has macular degeneration and does not want to take his medication.

B. A client who is taking insulin and has an HbA1c of 7%.

C. A client who has Graves' disease and has exophthalmos.

D. A client who is taking digoxin and is experiencing anorexia.

RATIONALES

A. Macular degeneration is a chronic condition that responds to medication; although the nurse should assess the client to determine why he does not want to take his medication, the nurse should assess another client first.

B. An HbA1C reflects a client’s blood glucose over the past three months; therefore, this is not the client the nurse should assess first.

C. Exophthalmos is an expected finding for a client who has Graves' disease; therefore, the nurse should assess another client first.

D. The nurse should recognize that anorexia is a possible indication of digoxin toxicity. Therefore, the nurse should assess this client first.

STABLE VS. UNSTABLE ITEM EXAMPLE

A nurse is reviewing laboratory data for 4 clients. Which of the following clients should the nurse assess first?

A. A client who has atherosclerosis with a total cholesterol level  of 250 mg/dL.

B. A client who has chronic kidney disease with a BUN of 80 mg/dL.

C. A client who is receiving warfarin with an INR of 4.0.

D. A client who is receiving furosemide and has a serum potassium of 3.8 mEq/L.

RATIONALES

A. The nurse should continue to monitor the client who has atherosclerosis and an elevated total cholesterol level; however, this client is stable and does not need to be assessed first.

B. The nurse should continue to monitor the client who has chronic kidney disease and an elevated BUN; however, this client is stable and does not need to be assessed first.

C. A client who is receiving warfarin and has an INR of 4.0 is at risk for hemorrhage. The nurse should assess this client first.

D. The nurse should continue to monitor the client who is receiving furosemide and has a potassium level within the expected reference range; however, this client is stable and does not need to be assessed first.

URGENT VS. NONURGENT ITEM EXAMPLE

A nurse is caring for a client who has peripheral arterial disease. Which of the following findings should the nurse report to the provider immediately?

A. Report of intermittent claudication

B. Shiny, hairless lower extremities

C. Absent dorsalis pedis pulse

D. Dependent rubor.

RATIONALES

A. Report of intermittent claudication is an important finding; however, it is common for clients with peripheral arterial disease to have this type of pain.

B. Shiny, hairless lower extremities is an important finding; however, clients with peripheral arterial disease usually develop this from long-term impaired circulation.

C. The priority finding is an absent dorsalis pedis pulse. This can indicate acute arterial occlusion, which requires immediate intervention.

D. Dependent rubor is an important finding; however, clients with peripheral arterial vascular disease usually develop this from long-term impaired circulation.

SURVIVAL POTENTIAL

This is a triage system used during mass-casualty events to determine priorities of care for all injured clients.

Triage classes graphicTriage categories

Emergent or immediate category (class I):

Red triage tag color

Highest priority is given to clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized.

Urgent or delayed category (class II):

Yellow triage tag color

Second-highest priority is given to clients who have major injuries that are not yet life-threatening and can usually wait 30 minutes to 2 hours for treatment.

Nonurgent or minimal category (class III):

Green triage tag color

The next-highest priority is given to clients who have minor injuries that are not life-threatening and do not need immediate attention.

Expectant category (class IV):

Black triage tag color

The lowest priority is given to clients who are not expected to live and are allowed to die naturally. Comfort measures can be provided, but restorative care is not.

ITEM EXAMPLE

A nurse is assessing clients at a mass-casualty event and placing the appropriate triage color tag on each client. Which of the following tags should the nurse assign to a client with an abdominal wound that has eviscerated?

A. Class I “emergent” tag
B. Class II “urgent” tag
C. Class III “nonurgent” tag
D. Class IV “expectant” tag

RATIONALES

A. A class I emergent tag indicates the client has injuries that are life-threatening and need immediate attention; therefore, the nurse should issue an emergent tag to this client.
B. A class II urgent tag indicates the client has injuries that need attention but are not life-threatening; therefore, the nurse should not issue an urgent tag to a client who has an abdominal wound that has eviscerated.
C. A class III nonurgent tag indicates the client has minor injuries that do not need immediate treatment; therefore, the nurse should not issue a nonurgent tag to a client who has an abdominal wound that has eviscerated.
D. A class IV expectant tag indicates the client has injuries that are not consistent with life; therefore, the nurse should not issue an expectant tag to a client who has an abdominal wound that has eviscerated.

When you’re looking for more information on the Next Gen NCLEX and clinical judgment, visit the NGN Resource Center. And download our new Next Generation NCLEX Guidebook, the industry’s first and only all-encompassing reference for preparing for the changes coming in 2023.


WHAT NURSING FRAMEWORK DOES YOUR PROGRAM PREFER? WHY? SHARE IN THE COMMENTS BELOW.


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PEOPLE ALSO ASK ...

WILL THE NEXTGEN BE HARDER?

The Next Gen NCLEX will be a more complicated test than the current version of the exam. Rather than only asking questions about nursing knowledge, it will also assess candidates' clinical judgment skills. As a result, the NGN will include new item types that are in entirely different formats than have been used in the past. These new item types require more complex technology and support to be able to score them, but the result is expected to help nursing education prepare more practice-ready nurses.

IS THE RN NCLEX CHANGING IN 2023?

The NCLEX-RN and the NCLEX-PN will both change to a new version of the licensure exam starting on April 1, 2023. This new version of the exam will assess candidates' clinical judgment skills, which are necessary based on practice analyses that the NCSBN has conducted over the last few years. New nurses now must be practice-ready earlier than their predecessors, who generally could build up their knowledge over several years.

WHAT WON'T CHANGE ON THE NEXT GEN NCLEX?

The majority of the Next Generation NCLEX (NGN) will remain focused on nursing knowledge questions, so the overall content that it covers will be primarily the same. The exam will remain computer adaptive, and most questions will be "standard" NCLEX items. Additionally, the scoring scale will not change.