Decision Tree:
This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.
This is a Priority Question.
Priority questions use words such as most, best, first, immediate, etc.
STEP 1: Can you identify the topic of the question?
- Priority item to have at bedside with paracentesis.
STEP 2: Are the answer choices assessment or implementation?
Assessment vs. Implementation
1. Tape measure. Assessment
2. Emesis basin. Implementation
3. Blood pressure cuff. Assessment
4. Scale. Implementation
Is assessment data or validation of assessment data needed? Yes, the client undergoing a paracentesis will require assessment. A tape measure, blood pressure cuff, and scale will all be used while assessing the client. Vomiting is not expected. Eliminate #2. Move to Step 3.
STEP 3: Apply Maslow: Are the answer choices physical or psychosocial?
Maslow
1. Tape measure. Physical
3. Blood pressure cuff. Physical
4. Scale. Physical
Because a mix of physical and psychosocial answer choices does not exist, answer choices cannot be eliminated at this step. Move to Step 4.
STEP 4: Are the answer choices related to ABCs?
ABCs
1. Tape measure. N/A
3. Blood pressure cuff. Circulation
4. Scale. N/A
ABC answer options take priority over non-ABC answer options if they make sense to the topic of the question. Eliminate #1 and #4.
STEP 5: What is the outcome of each of the remaining answer choices?
Evaluate the outcome(s)
3. Blood pressure cuff. This client is at risk for experiencing a fluid shift and hypotension.
Select the best choice:
Is #3 the correct answer? Yes, assessing the client?s BP will ensure early detection of hypotension from fluid shifts.
Does #3 make sense? Yes, when large amounts of fluid are removed, fluid shifting occurs and the BP may drop.
