Patient Prioritization Practice Questions with Answers and NCLEX® Review

Prioritization of client care is a crucial skill for nurses. Once you have the knowledge and skills necessary to take care of clients (patients), you need to know how to prioritize who needs the care most and first.

Patient Prioritization Practice Questions with Answers and Practice Questions

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    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.

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    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. 

    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.

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    Amy Stricklen
    “

    During my exam, I could literally see and hear him going over different areas as I was answering my questions.

    This past Friday I retook my Maternity Hesi and this time, I decided for my last week of Holiday break to just watch all of his OB videos. I am proud to say that with Mike’s help I received a score of 928 on my Maternity Hesi!

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    Amy Stricklen

    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.

    Sources

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

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