The concepts of prioritization, delegation, and assignment are among the most challenging for nursing students and new nurses. Many NCLEX-RN exam questions test your ability to prioritize nursing actions.
To develop these skills, let's review four basic concepts used to answer priority questions. Key strategic words indicating the need to prioritize include: first, essential, best, next, most important, highest priority, most or least appropriate, and most or least likely, vital, or primary. In these questions, all options might be correct, requiring you to determine the correct order of action.
Four Basic Concepts Used to Prioritize
I. ABCs
A frequently encountered priority question is the “ABC” question. In these scenarios, you must determine the most critical action related to the patient’s airway, breathing, and circulation. For instance, you might be asked what initial steps to take if a patient has difficulty breathing or a compromised airway.
Airway, breathing, and circulation, often referred to by the mnemonic “ABCs,” are essential for nurses when prioritizing care. Focusing on the ABCs ensures attention to the most vital needs for sustaining life. If a patient lacks a clear airway, cannot breathe, or has poor circulation, other interventions become insignificant. The ABCs align with the fundamental physiological needs in Maslow’s hierarchy and guide critical nursing actions and prompt interventions.
Sample ABCs question:
A 16-year-old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient’s care?
A. Perform postural drainage and chest physiotherapy every 4 hours
B. Allow the patient to decide whether she needs aerosolized medications
C. Place the patient in a private room to decrease the risk of further infection
D. Plan activities to allow at least 8 hours of uninterrupted sleep
Correct Answer
A. Perform postural drainage and chest physiotherapy every 4 hours
Explanation
Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over the other activities. Although allowing more independent decision making is important for adolescents. the physiologic need for improved respiratory function takes precedence at this time. A private room may be desirable for the patient but is not necessary. With increased shortness of breath. it will be more important that the patient have frequent respiratory treatments than 8 hours of sleep.
II. Maslow's Hierarchy of Needs
Another typical priority question involves “Maslow’s Hierarchy of Needs.” These questions test your knowledge of basic human needs and require you to prioritize actions accordingly.
Maslow's hierarchy of needs is commonly depicted as a pyramid, where the base represents essential needs that must be met before advancing to higher levels. At the foundational level of Maslow’s Hierarchy of Needs are physiological needs, which include oxygen, food, water, sex, sleep, homeostasis, and excretion. The second tier consists of safety needs, which encompass factors that protect individuals from harm, such as fall precautions in healthcare settings. The third level addresses emotional needs like love and a sense of belonging, often reflected in relationships with family and friends. The top two levels of the hierarchy involve esteem and self-actualization.
Sample Question:
The older adult has been admitted with right-sided weakness and a history of falls. Which nursing diagnosis has the highest priority for this patient?
A) Self-Care Deficit
B) Risk for Injury
C) Impaired Physical Mobility
D) Impaired Home Maintenance
Patient safety is a priority next to physiologic needs. The correct answer is B.
III. The Nursing Process
The Nursing Process is a crucial framework for guiding decision-making and actions in nursing. The ADPIE mnemonic helps remember the steps:
- Assessment
- Diagnosis/Analysis
- Planning
- Implementation
- Evaluation
These steps should be followed sequentially, with assessment always being the first step. It's important to remember to always conduct an assessment before implementing any interventions.
Sample Question:
Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?
A. Call for help to get the client back in bed.
B. Establish whether the client is responsive.
C. Assist the client back to bed.
D. Ask the client what happened.
Correct Answer
B. Establish whether the client is responsive.
Explanation
Assess first for responsiveness.
IV. Acute Versus Chronic Conditions and Unexpected Versus Expected Conditions
Another concept nurses use to prioritize care is distinguishing whether a condition or symptom is acute or chronic, expected or unexpected.
Acute conditions are characterized by a sudden and severe onset, usually resulting from a sudden illness or injury, and provoke a significant response from the body as it attempts to adapt.
In contrast, chronic conditions develop slowly and may progressively worsen over time. The main difference between acute and chronic conditions lies in the body's adaptation response. Individuals with chronic conditions often have less severe symptom flare-ups because their bodies have had time to adjust to the ongoing illness or injury.
Unexpected Versus Expected Conditions
In addition to considering acute versus chronic conditions, it is crucial to determine whether a patient’s signs and symptoms are “expected” or “unexpected” based on their overall condition.
Unexpected conditions are findings that are not typically seen in the normal progression of an illness, disease, or injury. Conversely, expected conditions are those that are likely or anticipated during the course of an illness, disease, or injury.
It is important to know what are expected signs and symptoms of the disease so that you can recognize deviations or a "sudden change". Unexpected findings usually necessitate immediate action by the nurse.
Sample Question:
Which client is the priority:
A. Client with asthma with a wheeze receiving a nebulizer.
B. Client with COPD and a pulse ox of 90% complaining of shortness of breath.
C. Client with a cast for a broken leg complaining of persistent pain in their extremity.
D. Client with pneumonia and a fever of 101.
A is an airway issue, but it's a chronic condition and it's already being addressed. B is a chronic condition, and the client is showing expected manifestations. We'll check them out, but a pulse ox of 90% is fine in a COPD patient. D? A fever of 101 isn't unexpected in pneumonia.
The correct answer is C. The other problems are either already being addressed, are expected, or are potential problems. The compartment syndrome patient is about to lose a leg if nothing is done now.
References:
THE BEST NURSING CONCEPTS FOR CLINICAL JUDGMENT & THE NEW NCLEX (atitesting.com)
Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 2 - Prioritization. Available from: https://www.ncbi.nlm.nih.gov/books/NBK598386/
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