Ahh, the NBRC’s dreaded Clinical Sims Examination, a one way ticket to a full-blown panic attack for any fresh RT graduate hoping to earn their RRT. Luckily there are methods that can help you navigate through the exam and keep you focused on clicking on the right choices.
Today we are going to reveal the best way to approach the Information Gathering sections of the NBRC Simulations exam. The strategy we will use will help you obtain as many points as possible in order to buffer the more difficult Decision Making sections of the exam.
Remember good decisions can reward your score with up to +3 points while poor decisions can deduct or -3 points from your score. In the end this is a game of points so choose wisely and do not get click happy!
- So, if you have taken some time practicing the Clinical Sims you have probably noticed the Information Gathering sections have the choices listed in random order. This is to entice you into picking the attractive ABG or CXR before starting with your basic assessments, like checking for a pulse or chest rise. Do not fall for these traps! Instead, start simple and then move towards the more complex testing later, those more complex tests will show up again later.
- Remember that once you are in a Stage you should select all options within that Stage before moving on to the next stage.
This is where you want to use your eyes and ears to observe and collect data quickly about your patient before you jump into lengthier tests such as an ABG or labs that may not be appropriate yet for your patient.
Imagine you are walking into a patients room. What can you see or hear about your patient without making actual contact with them? This is what you want to select first.
- Respiratory Rate and Pattern
- Chest Movement/Inspection
- Sensorium/Level of Consciousness – alert and orientated x 3
- Color/Skin Appearance
- Heart Rate
- General/Physical Appearance
- Nail beds
- Accessory Muscle Use
- Nature/Strength of Cough
- WOB – Work of Breathing
- Digital Clubbing – COPD
- Quantity and Consistency of Sputum
- Pupils – head injury, drug overdose
- History of Present Illness/Medical History/Height and Weight
Ok, so you made it past all the Stage 1 selections, now what? Make sure there is no emergency or intervention required at this time.
- If there is an obvious need for an airway or O2 then move to the next page and find the most appropriate action to take.
- If you are unsure of your pt.’s status or how to intervene go to Stage 2.
Here you have moved up to the patient’s bedside and are now physically interacting with them. You can perform simple bedside assessments but nothing that requires waiting for results.
Imagine you are standing next to the patient and can now perform fairly quick assessments.
- Breath Sounds/Chest Auscultation – nearly always used if they are breathing
- Pulse – this may also be used in Stage 1
- Blood Pressure
- Vital Capacity – Guillain-Barre, Myasthenia Gravis, Muscular Dystrophy, vent weaning
- MIP – Guillain Barre, Myasthenia Gravis, Muscular Dystrophy, vent weaning
- Peak Flow –asthma, do not use for COPD
- Percussion – Pneumothorax, areas of hyperinflation or consolidation/fluid
- Temperature – infection evidence
- Heart Sounds – congenital heart defect, valve issue, S1 and S2 normal
- Spontaneous VT – strange but a bedside spirometer can be used. If under 5ml/kg then use some vent support. Anything under 300 ml for an adult may be inadequate – make a ventilation selection on Decision Making to remedy this.
Still no emergency or need to intervene? Great! Then go for the bread and butter of RT assessment, the tests that will likely seal the deal with Decision Making.
Remember these results can take more time to obtain so make sure you are not wasting time on these when you know already how to treat the patient. Also do not keep repeating these tests back to back if no real changes to the patients status have occurred.
- ABG – will help with O2 decisions, to intubate or not, vent changes if on the vent, the meat and potatoes of assessments -just make sure you can make it to Stage 3 before selecting. Would be a -3 for you if they had no pulse and you selected the ABG first!
- Chest Radiograph/CXR – ETT placement, lines, where is the consolidation, atelectasis, how expanded are the lungs, etc.
- EKG/12 lead – chest pain, cardiac issues
- Labs: CBC, Serum Electrolytes – WBC are priceless to determine if infection present
- Sputum Culture and Sensitivity – what’s growing in there? Do I need a specific antibiotic? Remember to use if signs of respiratory infection – fever, high WBC, colored sputum
Still no emergency or major issues to fix? Not sure what to do? Maybe try one of these out, but only if it fits with the symptoms.
Also, keep in mind, most of these examples are pathology dependent and should not be selected unless you feel it will give you some beneficial info. They are going to be more expensive and time-consuming so you do not want to select these due to a fear of missing something.
If you are going to error in skipping a potentially harmful test, leave these out unless you are willing to justify the cost and time needed to perform.
- CT angiography of the chest – suspect Pulmonary Embolism (PE)
- Echocardiogram – heart defect in neo or cardiac pt.
- Sweat Chloride – only if suspect undiagnosed Cystic Fibrosis, don’t repeat if they are already diagnosed with CF
- VQ Scan – still trying to find that pesky PE
- Tensilon Test (Edrophonium) – only for Myasthenia Gravis, remember Mind to Ground
- PFT Testing
- Swallow/Aspiration Studies – muscular dystrophy, weakness, evidence of suspected aspiration
- Sleep Study – pt. drowsy during the day, snoring and interrupted sleep at night