D-Day: Operation NCLEX-RN

After proceeding through various security measures—fingerprints, photographs, and palm vein scans—I sat in front of that infamous computer terminal. The last two-and-a-half years of my life had been leading up to this moment. I took a deep breath and clicked “Start.”

It wasn’t that bad—I kind of pretended I was sitting at home doing practice questions on my laptop. I had beyond my fair share of the dreaded SATAs (select all that apply) which supposedly is a good sign—I’ve heard that they’re considered upper-level questions and if you’re getting a lot of them then more than likely you’re above the passing line.

For those of you who may not know, the NCLEX-RN can be anywhere from 75 to 265 questions (which is why they give you up to six hours to complete the exam). Obviously, everyone wants to only get 75 questions. And most people whose exam cuts off after 75 questions do seem to pass. But it’s all about demonstrating minimum competency. If you’ve accomplished that by 75 questions then that’s great but if not the computer will usually continue to give you more questions so that you can try to dig yourself “out of the hole” so-to-speak and get above that line. Contrary to popular belief, it is also possible to fail with 75 questions. How you answer those first 20 or so questions sort of determines your general competence level. Get most of them right and you position yourself comfortably above the passing line; however if you start off not doing so hot…

After I clicked the radio button for my answer to #75, I hovered my mouse hesitantly over the “Next” button. With one eye shut, holding my breath (and before I passed out), I clicked…and the screen went blank!

It was over!!

Afterward there’s a survey, another palm vein scan (they wanna make sure you’re still you and all), and they send you packing.

And then you wait…

This is truly the nerve-wracking part. The waiting. Official exam results can take weeks to receive in the mail; quick-results can’t be obtained for 48 hours. What on earth are you supposed to do in the meantime? Most people opt for the “Pearson Vue Trick” aka “PVT.” This is an unofficial way of checking whether you passed or not. Basically you log on and attempt to register for the exam again. If the system doesn’t allow you to register again and you get a popup that says something along the lines of “you’ve already registered for this exam, contact your board” you passed. However, if the credit card page comes up, then…sorry, you did not. A nifty little step-by-step guide can be found here.

So I did the PVT and got the “good” popup (make sure the status says “delivery successful” otherwise it’s too early to do it) so I was feeling pretty good. And the very next day my RN license was already posted on the state website—I don’t think you can get much more official than that! I’m a nurse! 😀

To those who have yet to take the exam be encouraged, be confident, and kick NCLEX butt! Good luck!

What Nursing Shortage???

I came across an article today about how even in this “nationwide shortage of nurses,” one of our local nursing schools’ grads can’t find jobs. So let’s have at this so-called nursing shortage thing.

Many people think it’s the economy. The hiring freezes. That nurses are working to later ages—even past retirement. Among other things. And all of those things probably do contribute to the problem. But this is my spin on the situation. I live in the Delaware Valley / Greater Philadelphia area. IMHO (and what do I know anyway?), I don’t believe there is a nursing shortage here. Why? Because this area is just too saturated with nursing schools. Diploma programs, and ADN programs, and BSN programs oh my! There are day programs and there are evening/weekend programs. There are even various accelerated programs (such as Villanova’s BSNExpress, Jefferson’s FACT, and Drexel’s ACE) that are pumping out new nurses as fast as every 11 months!

Now what surprises me most about not a single one of the AMH Dixon SON grads being able to secure a job yet is that the school is part of a hospital. A lot of their students do in fact think that gives them an edge as far as securing a job after graduation—which evidently is not the case. I have noticed job postings on AMH’s website for “Clinical Associates” (tech-type positions) which are only open to their own nursing students—why not initiate something similar for their graduates? One would think they’d be able to hire at least some of their own grad nurses.

Secondly, Abington is a diploma program. Though they have recently partnered with Jefferson to offer an RN-BSN or RN-BSN/MSN option after you’ve completed their program, that really doesn’t help the new grads right now, with their fresh diplomas in hand. And depending on where/what type of setting (hospital, etc.) you’d like to work at as an RN, know that many of the major players (at least in this area) are now moving from a “BSN-preferred” to a “BSN-required” model. Just food for thought.

Before anyone gets their panties in a twist, please know I am in no way bashing Abington or any of the other diploma or ADN programs—in fact, I almost went to Abington. It’s a great school, the faculty that I’d dealt with were great, and they have stellar NCLEX pass rates—though if it’s anything like my program the bad test-takers and flat-out slackers are weeded out of the program way before you get anywhere near the NCLEX (which is why I never really considered NCLEX pass rates as a determinant of how good a program was). But in the end I decided that it would be best for me to pursue the BSN. Besides the fact that I just couldn’t wrap my head around going to school for 2 years and just getting a diploma when I could go for an extra semester and get a BSN, again, where and what type of position I plan to pursue after graduation requires the latter. That’s just the way the cookie crumbles.

So is there really a nursing shortage? Maybe—in Texas, California, or the Midwest—but not so much here in the city of Brotherly Love…

VEAL CHOP

Let me tell you a little secret–nursing students LOVE mnemonics. There would be absolutely no way to store all of the information we need to know without them. You’ve got the basics like “ADPIE” (which is the nursing process: assessment, diagnosis, planning, intervention, and evaluation) and “OLDCARTS”  (the attributes of a symptom: onset, location, duration, characteristics, aggravating factors, relieving factors, timing, and severity). Some others I’ve picked up so far are “Nancy Reagan, RN” (how to draw up a mixed insulin dose–air into NPH, air into Regular, draw up Regular, then draw up NPH); “LAB RAT” (left atrium: biscuspid; right atrium: tricuspid–which I always used to mix up!); and there are about gillion different ones for cranial nerves. I like “Olympic Opium Occupies Troubled Triathletes After Finishing Vegas Gambling Vacations Still High”–olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, vestibulocochlear/acoustic, glossopharyngeal, vagus, spinal accessory, and hypoglossal. Tonight, I learned a new one to add to the list–VEAL CHOP–which relates to fetal heart rate.

Variable decels => Cord compression (usually a change in mother’s position helps)

Early decels => Head compression (decels mirror the contractions; this is not a sign of fetal problems)

Accelerations => O₂ (baby is well oxygenated–this is good)

Late decels => Placental utero insufficiency (this is bad and means there is decreased perfusion of blood/oxygen/nutrients to the baby). You’ll also hear/see this called “uteroplacental insufficiency,” but VEAL CHOU just doesn’t have the same ring to it does it?

And that’s our lesson for today folks. It’s only the first lecture but so far I think I’m really going to like this class. My professor is really on the ball and I actually didn’t mind that she kept us until the last minute of class because the material was interesting and I felt like I was actually learning something–like the stages of labor (not to be confused with the phases which all occur during the 1st stage) and the 5 P’s (powers, passage, passenger, psyche, and position). I think I’m almost ready to catch a baby–clinical starts on Saturday! 🙂

Nurse Nasty Not Niceness

Last clinical weekend I had a nurse from hell. Not only was she nasty to me, but her attitude even trickled down to my (I guess I should say “our”) patient.  The day started out how clinical days usually do, getting up at the butt-crack of dawn, hot-wheeling (as my children would say) to the hospital with just enough time to grab a cup of Starbucks before running in for report. I find the nurse I’m assigned to—”B”— introduce myself, tell her I’m assigned to such-an-such a patient…all that good stuff. She looks at me like I have three heads. I shrug it off—it’s too early, we’re all a little grumpy and most of us are waiting for the caffeine to kick in. She grudgingly pulls out her little notes to give me report. She tells me a few relevant things about the patient, but mostly just complains that she was “too young to need such total care.” She then asks (herself I’m guessing, because how the hell would I know), “Is this ‘the one’ with MRSA?” And proceeds to go back and forth in monologue about whether or not the patient had MRSA–something you’d kinda wanna to know before going in the patient’s room. We finally did establish that the patient did not in fact have MRSA.

So I go to check on the patient, introduce myself, etc. She’d had a dilaudid PCA from which she was being weaned (or actually by the time I got to her it had already been dc’d). Poor thing was clearly in pain and was wondering why her IV “didn’t seem to be working” so apparently no one had talked with her about it. I got my own set of vitals and asked her to rate her pain for me—which she of course rated as a 10 on a scale from 0 to 10. I reported this back to “B” who replies unsympathetically —“Oh well, she ain’t getting nothing else.” OH-KAY… The patient recently had a lumbar laminectomy, was discharged, then fell and broke her wrist. So she’s laying here with post surgery back pain, which was most likely made worse by her fall, a splint holding her broken left wrist together, and an IV in her right arm which was clearly infiltrated—unpleasant to say the least. So right about now, I’m stumped. Am I supposed to go in and tell my patient that her “real” nurse doesn’t give a crap that she’s in pain?

I return to the patient’s room to find breakfast trays are being delivered—good—a welcomed distraction. I helped her get set up—between the splint and the IV she really had limited use of her hands. She relaxed a little as we talked, but as the last traces of dilaudid wore off you could tell the pain was beginning to bother her again. Usually after breakfast we do hygiene and personal care, but she refused as she was in too much pain and did not want to be touched. I let her be for the meantime and decided to get started with my meds. Nurse Ratched finally allowed me to see my patient’s MAR (medication administration record), so I was able to look up the meds I didn’t know. She did not want to give me the key, nor let me into the drawer so that I could pull my meds. “You don’t need ME, you NEED YOUR INSTRUCTOR!” she snapped. Now at this point I’m seriously wondering what is this chicks’ malfunction? I went to find my instructor, who mind you is running around like a chicken with her head off helping all six of us pull meds (this was the first weekend that ALL of us did meds, previously just one or two of us would). After I returned with my instructor, “B” didn’t want to give her the key to the damn med drawer either!! She walked her devil-red scrubbed arse down to the room with us in tow, unlocked the drawer, and left without a word. Why couldn’t she have just done that 20 minutes ago? So I pull my meds, my instructor double-checks them, and then down the patient’s hatch they go.

At the beginning of the day the nurses were informed that the students would only be doing PO (oral) meds and injections—no IVs. Lo and behold we’re meeting with our clinical instructor in the cafeteria and Nurse Nasty hunts us down, MAR in hand—mind you the unit is two floors up, over the river and through the woods. “Why didn’t you give the such-and-such?” (I don’t remember what it was). I responded that was an IV medication. “Well how was I supposed to know you weren’t giving it?” Now she was really beginning to annoy me. If she took the time to actually l@@k at the MAR which she snatched back from me seconds after I gave the PO meds, she would have seen that I had not signed off on the IV medication—hence I did not give it! My instructor also added “I informed all of you this morning that the students would only be giving PO meds and injections today.” Nurse Nasty turns and leaves, horns just a-glistening. When we returned to the unit she now wanted to know why I also neglected to sign off on the patient’s Desenex powder, “You haven’t even bathed her yet…well what exactly ARE you doing today?” Nurse Nasty aparently forgot that “50” (she referred to all of her patients by room number and not by name) refused hygiene because SHE refused to acknowledge her pain status! Why would I apply desenex powder to a soiled ass behind?!? I figured we (more like I) could give it another try a little later after the oxycontin I had given her had a chance to kick in and her pain was a little more under wraps. Needless to say I could not wait for this day to end.

I realize that most of the time the nurses aren’t given a choice as to whether or not they will have a student nurse—I get that. The clear discontent of some of them is quite evident. And while they may be good at their jobs, some clearly do not have the right attitude to teach. But do they have to take out their frustration on us and even worse, the patients?!? Can’t they remember back to when they themselves were students? Sometimes I really do wonder why certain people have chosen this profession.

Thankfully, the next day I was not assigned to any of Nurse Nasty’s patients (which by the way, sucked for one of my classmates). I had a great nurse and two patients both of whom asked if they could take me home with them :). It was also the first time that I had more than one patient so I was busy—vitals, breakfast, baths, meds, fall risks, bed monitors going off, safety checklists, care plans…the whole shebang. My older patient (I believe she was 85-yrs-old) had literally about 15 9 a.m. PO meds. It took her three tall cups of water and about 30 minutes to get them all down. On top of the PO meds I had to give her a subcutaneous lovenox injection, “up close and personal,” as she called it. But I must admit that I do love when I give injections and they ask “are you done already?!?” It was an exhausting yet exhilarating day, and before I knew it, it was over.

We have clinicals again this weekend so we’ll see if Nurse Nasty remembers to take her happy pill. I guess sometimes the devil doesn’t wear Prada, but scrubs…

Foleys, Injections, and Wound Care–Oh My!

We finally had the dreaded “math/drug calculation exam”—the one you need to get an A on or fail the course (though they do give you 3 tries before they cut you loose). I’ve always heard nursing students making such a big deal out of this exam, claiming to have lost sleep (and even hair) over it. It did take memorizing some of the lesser known conversions like 1 grain = 60 milligrams and 30 milliliters = 1 ounce, but it really wasn’t that bad. Aced it—100%. I think a lot of the stress nursing students experience comes from all of the melodrama and sensationalism they attach to everything. Chillax already—when one of us gets all worked up about something it is contagious—it spreads through the class faster than a fire in a grease pit. Not that I don’t have my own fair share of stress and worry, but the level of agitation among some of these students gives me flashbacks of my days working in inpatient psych—sheesh.

The other big kahuna (at least for a first semester nursing student) was skills testing. You basically rotate through several “stations” and demonstrate each skill. You have to get at least a 75 on each one or you have to return for remediation (*enter scary music*). So for the past six weeks we have been in the lab learning skills—vital signs, injections, catheter insertion, wound care…among other things. The lab was then available for “open lab” for those who wanted to practice before the actual testing. After one open lab it became evident that different groups were learning different techniques, some of them outrageously (and dangerously) as the Grinch would say—WRONG-O! I saw one student do a Z-track by making an actual Z with the needle as she withdrew it—what in the world?!? You’re supposed to withdraw the needle at the same angle it was inserted (straight out)…I wonder how many degrees a “Z” angle would be…

The actual testing went well. Got there early, but of course they were running behind schedule. Students were in the hallway trying to cram last-minute bits of information into their already encumbered semantic memories (“what’s systolic pressure again?”…). Finally it was my turn. First up was the Foley, which I was to insert into a female manikin (no live volunteers for this one, LOL). So the big issue with catheter insertion is not breaking the sterile field. But I was fine, took my time and talked my way through it. Next up was vital signs which were a no-brainer, then medication administration/injections. I had to select the appropriate needle and injection site (though she made me name all of them anyway). I was given an “order” to mix 10 units of regular insulin with 20 units of NPH. No problem, thanks to the mnemonic “Nancy Regan, RN.” So after all of the default stuff (5 rights, etc.), I draw up 30 units of air, inject 20 into the airspace of the NPH, then 10 units into the Regular, invert the vial, draw 10 units of Regular, then go back and draw 20 units of NPH—piece of cake right? I give my imaginary patient a 90° injection (instead of a 45° since my 85-yr-old “patient” is very thin) into her imaginary abdomen (which is actually a square pad of something nasty and gel-like, filled with the millions of injections it had received before mine). Meanwhile, the tester is firing questions at me, but at this point I’m like “Bam–ok, what else you got?” My last station was wound care—remove the dressing, measure the wound, irrigate, culture, and redress. It was a medical asepsis and not a sterile procedure so I didn’t have to worry about breaking any fields (just changing my gloves fifty times). Once you pass through all the stations the tester tallies up your grade, you sign off on it, and they send you on your merry (or unmerry for some) way.

After it was finally over and I emerged from the lab unscathed as opposed to running from the room crying and screaming with my hair on fire, there were about 5 students still anxiously waiting in the hall all staring at me with this look on their faces—“Well?!? Did you pass?” Of course I did, no sweat…