The why and the what

NEXT GENERATION NCLEX The why and the what

Why the change?

The majority of employers are not satisfied with the performance of new graduate nurses. Most employers feel that new graduate nurses lack the necessary critical thinking to make the complex decisions that nursing requires. The new generation questions aim to test new graduate nurses’ ability to use critical thinking in clinical reasoning and decision making. So let’s go through the thinking process that is required in the new generation NCLEX questions.

What is required of your cognitive skills?

It is about the creation of a NEW nursing process that is a little more comprehensive.
Here are the new clinical judgment cognitive skills you are expected to have:
- Recognize Cues: What matters most to save the patient NOW? What are the priorities?
- Analyze Cues: What do the current probems/vital signs/abnormal findings mean?
- Prioritize Hypothesis: Where do I start to solve the problems/abnormal findings? What do I have to follow up immediately and what can wait?
- Generate Solutions: What can I do to make it better or to prevent complications?
- Take Action: What action/actions will I take now?
- Evaluate Outcomes: Did my nursing interventions help or has the client’s condition declined? How do I know?
- Don’t worry. We will go through each one of these cognitive skills. We will provide examples.

Recognize Cues

What is a cue? A signal that something is wrong or right.
Cues are signs and symptoms or findings that point to a disease process or a complicationCues can be lab values that support certain conditions.
Cues can be changes in condition such as improved/worsening vital signs, physical assessment findings, and/or behaviors.
How do you recognize these cues? Look at the physical assessment, the medical record, the vital signs, the test results, the different trends and changes in condition.
Learn to ignore distractors, which are findings that are not currently relevant. For example, a client in renal failure is expected to have an elevated BUN and creatinine. Ignore that. It is not a priority. However, if the client is expected to have healthy kidneys and the BUN and creatinine are elevated, then it is a priority.
Don’t let distractors distract you. Dumb to say, I know. But I want you to remember to pay attention to the whole picture and to what currently matters. What will improve the client’s condition right here and right now? But how do you know what matters most? Study content. Each of the questions in my modules provide you with content. I provide you with illustrated rationales that are easy to remember.
I do not waste time with unnecessary content, but focus on the most commonly tested material on the NCLEX.

Click on the tabs to reveal information

History of Present illness

Nurses Notes

Labs, Vital Signs, & Tests

History of Present illness

Nurses Notes

Labs, Vital Signs, & Tests

Recognize Cues

What matters most, right here, right NOW?

Findings	Normal/Abnormal but irrelevant	Abnormal/Needs Follow Up
Tachycardia		X (Elevated)
Hypotension		X (Blood Pressure is low)
CT Scan results	X (Expected for an elderly person to have degenerative changes)
Urinary Symptoms		X (Points to possible UTI/Urosepsis).
Neurological Assessment		X (Client is confused and lethargic)
Respiratory Rate	X (Rate is normal. It is unlabored).

Analyze Cues

What do the cues mean in this scenario?
What problem are the cues pointing to?

Analyze Cues

Condition	Findings that Support Condition	Findings that exclude condition
Dehydration	Tachycardia, hypotension, dry mouth, poorly taken care of to the point of dehydration
Osteoporosis	Elderly small Asian women are at very high risk for Osteoporosis. Plus hip fracture
Urinary Tract Infection (possibly urosepsis)	Frequency, smell of urine, tachycardia and hypotension.
Diabetic Ketoacidosis		She is diabetic type 2. DKA is for type 1 and Hyperosmolar Hyperglycemic state is for type 2 diabetes. Know this!
Elder Abuse	Poor hygiene and malnourished. No one is doing her ADLs, that's potential abuse
Cerebral Vascular Accident		CT scan is normal for her age. Degenerative changes are expected.

Here is another Analyze Cues Question

Here, analyzing cues is about knowing the signs and symptoms of two conditions by comparing them. But to do this, you need to acquire knowledge. Remember to study content! Don’t just focus on answering questions. This is how my modules differ. I use a concept called scaffolding. I learned it while doing my master’s in rhetoric and composition. I wish I would have understood this concept when I was doing my master’s in nursing at UCLA. Scaffolding, as used in my modules, is about taking several stages in learning/answering NCLEX questions. I start with a quick lesson about the condition or disease, then I use simple questions to make sure you know the facts. Yes, there are facts in nursing. Without those facts you cannot recognize/analyze/prioritize and so on. Without the facts, there is no advanced critical thinking. I called this short, quick questions “FAST KNOWLEDGE.” Let me give you an example. Then I move on with more complex questions

Sets of questions like this one help you acquire/test your knowledge. Of course, before presenting these questions, I provide an illustration to help differentiate between Diabetes Insipidus and SIADH. Also, these simple true and false questions are derived from more complex questions in sources such as UWorld, Kaplan, and Saunders. Questions were short, right? Well you just answered what seemed to be long complex questions found in the popular NCLEX review sources.

Prioritize Hypothesis

In Prioritize Hypothesis, you must evaluate each of the client’s needs and decide what health problems are priority. What problem(s) you must address first in order to save the client’s life and/or improve his or her clinical condition.
Here is an example with a Multiple Choice Single Response Item. (Don’t worry, we will discuss the different question types after this section).

Let’s see, first we recognize the cues. Flat line on the EKG.
Second, Analyze the cues: flat line can mean 1) asystole or 2) a lead came off.
Now, let’s prioritize. What should we do first to meet the client’s needs?
Let’s make sure patient is responsive. If patient is responsive then a lead came off. Simple. Never start CPR or give epinephrine before making sure client actually needs it!
But at the end of the day, it is about knowledge. If you know your CPR, you know that the first action is “are you okay?”

Generate Solutions

Generating solutions is about establishing nursing interventions to achieve the desired outcomes and about identifying actions that should be avoided since they are contraindicated/not helpful.

The nurse is caring for Mrs. Johnson, a 59-year-old female client admitted with congestive heart failure who has a history of DM II and a CVA 3 years ago. For each nursing intervention, type an “X” to specify whether it is an accepted intervention or a contraindicated intervention for this client.

Please know CHF like the back of your hand before you take the NCLEX. It is one of the most tested diseases on the NCLEX. HOB should be elevated > 30 º (or as high as possible) since it allows for better lung expansion. Limit fluids/Sodium and Monitor BNP (Brain Natriuretic Peptide), a hormone that increases with heart failure.

Take Action

Above we have several interventions for a client with heart failure. Some are accepted interventions, some are contraindicated. This is the time when you take action and implement the accepted interventions.

Let me give you a rationale using a drag and drop question, just for fun and to make sure you learn the treatment for major abnormal rhytms. Click on the green choice and then click on the yellow area where you want it to go.

Evaluate Outcomes

Evaluating outcomes is about knowing what assessment findings determine that the client’s condition has improved or declined. Let’s look at this next question in which you are expected to determine whether this client with congestive heart failure is ready to be discharged. SELECT ALL THAT APPLY

Knowledge is power!

Here, you need to know that gaining weight, especially 2 lbs over 24 hours is bad for a client with heart failure.
You also need to know that sleeping with more than 1 pillow at night means worsening heart failure. Orthopnea!
You need to know that in heart failure sodium needs to be limited and that BNP should be < 100. Ok, I guess the next gen NCLEX RN doesn’t expect you to know lab values. Also, you may question whether the BNP must be < 100 before discharge. After all, the client has heart failure and the BNP may be a little higher. Good thinking!
Take the time to know by studying Content.