Patient Prioritization Practice Questions with Answers and NCLEX® Review

Introduction to Prioritization in Nursing

Client prioritization for nurses is a complex, multi-step process that involves an in-depth analysis of each individual’s needs and goals. Assessment is key in determining each client’s current state, as well as their future goals and potential outcomes.

Nurses (and other staff) are often tasked with prioritizing clients in their care, from the most to least urgent. Prioritization helps utilize limited time and resources to provide the best possible care for clients.

ABC’s of Patient Prioritization

ABC stands for Airway, Breathing, and Circulation. As a nurse, your first job is to remember that these ABCs are the highest priority. 

Need help with your next exam? Our proven system has helped over 1,000,000 nursing students reduce their study time, survive their nursing school lectures and PASS their exams! SimpleNursing membership offers:

• 1,100 fun and visual videos covering the most highly tested topics in RN/PN nursing programs
• 900+ pages of cheat sheets & done-for-you study guides
• Test tips and memory tricks included

See how our members are
earning a 99% pass rate.
Get started now For Free

Maslow’s hierarchy of needs is another tool to help guide the nursing process. Maslow’s is a pyramid of needs. For example, a client with physiologic needs takes priority over love and belonging.

Maslow’s guides nurses to prioritize client care using an organized approach:

• Physiological needs
• Safety needs
• Love and belonging needs
• Esteem needs
• Self-actualization 

Here are some helpful guidelines to assist with the prioritization of clients:

Airway = blockage

• Stridor “squeak” – Postoperative Thyroid / Parathyroid
• Anaphylaxis: throat swelling – Epipen 1st!
• Ruptured esophageal varices – Turn to side-lying position

Breathing = RR & Oxygenation

• Low PaO2 (Norm: 80 – 100)
  • 60 or less = HypOXemic Respiratory failure
• High CO2
  • 50 or MORE = HyperCapnic Respiratory failure
• Hypoxia
  • Change LOC: Level of consciousness
  • Mental changes: Restless, agitation
  • Skin: Pale, dusky, cool & clammy
• SpO2% (Norm: 95 – 100%)
  • COPD – Low 90% is normal]

Circulation

• Bleeding:
  • Internal:
    • Hypotension “Low BP”
    • Hard stiff “board-like” abdomen
    • Skin: Pale, dusky, cool & clammy
  • Coagulation:
    • Platelets (norm: 150k – 400k)
      • Less than 150k – Thrombocytopenia
      • Less than 50k – VERY RISKY!
    • Heparin: PTT 46 – 70
    • Warfarin: INR 2 – 3
      • 3 x MAX range

Signs of Infection:

• Fever (this is sometimes the only sign of an infection).
• Chills and sweats.
• Cough
• Sore throat
• Difficulty breathing
• Nasal congestion
• Redness, or swelling in any area, including surgical wounds and IV access
• Burning or pain with urination
• Unusual vaginal discharge or irritation
• New onset of pain
• WBC over 10,000 or less than 1,500

Clients at Increased Risk of Infection:

• Neutropenic clients
• Clients receiving Chemotherapy, Immunosuppressants

Pain

Pain is on the lower end of the prioritization list since it is not always fatal. As a nurse, you must understand that prioritization is always based on choosing the client with a higher chance of dying. Pain can be managed, and the discomfort can be tolerated for a certain period of time.

Memory Trick – Lose life or limb

• Chest Pain = number one priority
• Cast or broken limb pain = pain unrelieved with pain meds

Labs in Patient Prioritization 

• Low glucose

• • • Less than 70 “Hypoglycemia”
    • Hypogly = Brain will DIE!

• Kidney complications

• • • Creatinine OVER 1.3 = Bad kidney!
    • Urine output 30 ml/hr or less = Kidneys in distress 
    • CT contrast
    • Antibiotics: Vancomycin & Gentamicin

• Toxic lab levels

• • Lithium 1.5 +
  • Digoxin 2.0 +
  • Theophylline 20 +
  • Phenytoin 20 + 

In prioritizing client care, things to consider are: 

• How will this affect the client if they are not taken care of immediately? 
• Are there tasks that can be delegated safely? 
• What can I do alone without the help of other staff? 

Client safety and nursing judgment go hand in hand with making key prioritization decisions.

Prioritization in Nursing Conclusion

Patient prioritization is a multi-step process involving a complicated analysis of each client’s needs and goals. Nurses need to assess each client’s current state and future goals in order to figure out which clients are most likely to benefit from additional attention.

The ABCs of patient prioritization are Airway, Breathing, and Circulation, which are the three things that must be addressed in any medical situation.

Client prioritization is a favorite topic in the majority of nursing exams. Why wouldn’t it be? A huge chunk of the National Boards and NCLEX^® questions fall under client prioritization and delegation.

Prioritization Matters

It is vital for nursing students to know how to prioritize clients to identify which client gets care first easily. Considering that nursing has a lot of elements involved and time management is vital, one must be critical in managing a wide array of responsibilities that can be quite overwhelming. Not only is this important in a hospital setting but also prioritizing gets quite tricky in the exams.

Sources

https://online.marymount.edu/blog/abcs-nursing-prioritization