Nursing Prioritization
Do you wonder how to priori:ze nursing care or answer NCLEX ques:ons?
There are a few tools you can use to determine how to priori:ze care:
1. ABCs
2. Maslow’s Hierarchy of Needs
3. The Nursing Process
ABCs
1. Airway 2. Breathing 3. Circula6on
• Do they have a patent • Are they breathing fast? • Do they have a pulse? (yes, if
airway? Slow? they are breathing in A/B)
• Are they choking or is the • Is it shallow, labored, or is • Is the pa:ent’s heart rate and
airway obstructed? there increased work of blood pressure stable?
• Head-:lt, chin-li= to open breathing? • Are they tachycardic or
airway. • Can you hear bilateral breath bradycardic?
• Do they need an OPA/NPA? sounds? • Any arrhythmia? EKG?
• Any stridor? • Any cyanosis? • Is their BP low? Are they in
• Is their mental status altered shock? Dehydrated,
to the point of not breathing? hypovolemic, bleeding?
• If GCS <8 = intubate! • Capillary refill?
• Warm/well perfused
extremi:es? Cool/clammy?
Maslow’s Hierarchy of Needs
1. Physiologic 2. Safety and 3. Love and 4. Self-esteem 5. Self-
needs security belonging actualiza6on
• Food • Fall preven:on • Build rapport • Esteem from • Highest level
• Water • Bed locked • Trus:ng self • Unlikely to be
• Vitals • Environmental rela:onship • Esteem from used during
• Pain safety • Acceptance others NCLEX ques:on
• Diges:on/ • Comfort from others – most will fall
elimina:on into first 3
levels of
hierarchy
The Nursing Process
1. Assess 2. Diagnose 3. Plan 4. Implement 5. Evaluate
• Gather • Create nursing • Plan out • Implement • Evaluate
assessment diagnoses for interven:ons to interven:ons effec:veness
data: actual or help actual or and modify
• Vitals poten:al poten:al interven:ons if
• Physical problems based problems needed
assessment on assessment
• Labs/imaging
©2023 by KatetheNP
General Tips for Answering Nursing Ques3ons
Do you struggle with nursing ques0ons, because all the answers seem right and you have to pick the
one that is most right? Or you would do all of the interven0ons listed, but which would you do first?
• Use your ABCs: airway and breathing are going to be priori0es – if your pa0ent doesn’t have an
airway or isn’t breathing, you don’t have a pa0ent.
• Maslow’s Hierarchy: typically for NLCEX ques0ons, the op0ons will usually fit into the first 1-3 0ers
of the hierarchy and physiologic needs will always need to be addressed first.
• Nursing process: most of the 0me, an answer that involves assessment is the correct answer. You
need to assess your pa0ent first in order to figure out the next steps that need to be taken.
• Know your normal labs/vital sign ranges. This will help to help answer ques0ons where you are
given pa0ent scenarios involving vitals/labs – you need to be able to tell which pa0ents have
abnormal findings to decide who to see or priori0ze.
• Ul0mately, ques0ons are looking to make sure you priori0ze the pa0ent at highest risk for death or
clinical deteriora0on.
• Although pain is distressing to pa0ents, when it comes to NCLEX ques0ons (especially compared
with the ABCs), a pa0ent won’t die from being in pain.
• Use the informa0on given to you in the ques0ons, without adding too much extra or answering by
what you see in clinical prac0ce. Pretend you have all the 0me, staff, supplies (aka a perfect world)
and answer appropriately based on the textbook (even it’s not real life).
• Look for key words in the ques0on: “best,” “first,” “immediate priority,” “lowest,” etc.
• Don’t forget that some ques0ons will ask you to select the least appropriate interven0on or ask
where you would do all of the following except something (keep in mind that 3 of the 4 responses
will be correct in this style ques0on).
• Know what you can and can’t delegate to LPN/CNA/other staff = can’t delegate assessment,
diagnosis, planning, or evalua0on parts of the nursing process and you can’t delegate educa0on/
pa0ent teaching.
• You are also as the RN s0ll responsible for the follow through (ex: abnormal vitals recorded by CNA
are s0ll RNs problem and ul0mate responsibility)!
• Remember the 5 rights of delega0on: right person, right task, right communica0on, right
circumstances, and right supervision.
Your pa0ent calls and says they can’t breathe. Their oxygen satura0on on is 88% on 2 L NC with a heart
rate of 95 and vital signs otherwise stable. What is the first interven0on the nurse should take?
A. Call the doctor.
B. Listen to the pa0ent’s lung sounds.
C. Ask the CNA to check the pa0ent’s blood sugar.
D. Draw blood for STAT labs.
The correct answer is B. Using the nursing process, the nurse should assess the pa3ent’s lungs (for
crackles, wheezes, adven33ous sounds, absence of air movement). The nurse will call the doctor (A),
but should assess the pa3ent first so they have that informa3on available to report to the physician.
The physician may order STAT labs (D), but they have not yet and the blood sugar (C) is a distractor.
Which of the following pa0ents should the nurse see first when star0ng their shig?
A. A pa0ent that arrived from the OR 2 hours ago and whose last blood pressure was 90/58.
B. A pa0ent that had a MI two days ago that is reques0ng a sleeping pill.
C. A pa0ent that has been in the hospital for 3 weeks, with chronic back pain, reques0ng pain
medica0ons.
D. A pa0ent whose daughter is reques0ng to speak to the nurse about her mom’s plan of care (and
visi0ng hours end in 15 minutes).
The correct answer is A. The pa3ent that came from the OR a few hours ago and also has a low BP (C
= circula3on - ABCs) is the pa3ent at highest risk for complica3ons and most unstable. Pa3ent B+C
have lower priority needs that can be aLended to later. Although the family member of pa3ent D is
leaving soon, the pa3ent in A takes priority due to their poten3al instability.
©2023 by KatetheNP
References consulted in the making of this study guide:
Burke, A. (2023). Establishing [Link]: NCLEX-RN. [Link]. h?ps://
[Link]/nclex/establishing-prioriFes/
MarFn, P. (2023). NCLEX .ps for nursing [Link], [Link], and assignment
[Link]. Nurseslabs. h?ps://[Link]/prioriFzaFon-delegaFon-
assignment-nclex-pracFce-quesFons/
Simple Nursing. (2022). How to [Link] care with Maslow’s hierarchy of needs.
h?ps://[Link]/maslows-hierarchy-of-needs-for-nursing/
Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth’s
textbook of medical surgical nursing (12th ed.). Wolters Kluwer.
