How to Answer NCLEX Prioritization Questions

How to answer NCLEX prioritization questions in five steps

Prioritization items usually carry a bolded word such as first, priority, initial, immediately or next. NCSBN bolds key words like these, and when the bolded word asks for order, assume more than one option may be reasonable and decide which comes first.

1. Restate each option in a few words: what is the problem, and is it new?
2. Cross off anything that is expected for the condition or procedure and still within its normal course.
3. Of what is left, pick an airway, breathing or circulation threat over everything else.
4. If none, pick the other physiological need, then the safety risk, then psychosocial and teaching needs.
5. Among actions for one client, assess before you act unless the situation is already clear and dangerous; then act first.

ABCs: airway, breathing, circulation

Airway comes before breathing, and breathing before circulation, because a blocked airway kills in minutes. When an airway, breathing or circulation problem is present, little else you do matters until it is fixed.

Watch for airway threats that are not yet obvious: stridor, a swollen neck after surgery, new hoarseness, tingling that hints at falling calcium, secretions with a falling saturation in a new tracheostomy. A threat that can progress to airway loss outranks a moderate problem that is already present.

Maslow: physiological needs before safety and the rest

Maslow's hierarchy puts physiological needs (oxygen, circulation, fluids, nutrition, elimination, temperature) at the base, then safety and security, then love and belonging (emotional needs), then esteem and self-actualization. Lower needs come first.

Use Maslow when no option is an ABC problem. A client with a fluid or glucose problem comes before a client at risk of falling, who comes before a client who is anxious about a diagnosis, who comes before a client asking for discharge teaching.

Acute vs chronic, and unstable vs expected

An acute problem starts suddenly and often signals a change in condition. A chronic problem develops slowly, and the client has usually adapted to it. Acute generally comes first. A saturation of 90% in a client with long-standing COPD is often that client's baseline; a new drop to 88% after surgery is not.

The same logic separates unexpected from expected findings. An expected finding is part of the normal course of the illness or procedure: incisional pain two days after surgery, drainage from a nasogastric tube, no bowel movement on day three after a hip replacement. An unexpected finding does not belong to that course, and it is the one the question wants.

Safety and risk: actual problems before potential ones

An actual problem is happening now; a risk problem has no current signs. Actual usually comes first. One useful way to grade urgency is critical (act now), urgent (discomfort or real safety risk), routine (daily care) and extras (comfort that can wait).

Two sample prioritization questions, worked through

Question 1: four surgical clients

Restate each option. Day 1 after thyroidectomy with tingling around the mouth and fingertips: new and unexpected. Day 2 after colon resection with 400 mL of nasogastric drainage overnight: expected; the tube is doing its job. Day 3 after hip replacement with no bowel movement: expected and routine. Day 1 after cholecystectomy with pain of 6: expected and treatable.

Only one finding is unexpected, and it is also an ABC problem in disguise. Perioral and fingertip tingling after thyroid surgery points to falling calcium from parathyroid injury, and hypocalcemia can progress to laryngospasm. The client with the potential airway problem is seen first.

Question 2: four lab results

Every value here is abnormal, so the test is which one can kill soonest. A white count of 14,000 in pneumonia is expected and is already being treated. A hemoglobin of 9.8 in chronic iron-deficiency anemia is low but familiar. An INR of 2.6 on warfarin for atrial fibrillation sits inside the labeled target range of 2.0 to 3.0.

A potassium of 6.7 is severe hyperkalemia, and it can cause fatal dysrhythmias whether or not the kidney disease is chronic. This is the trap from the warning above: the word chronic makes the option look stable, but the number is what matters. On the NCLEX, items with a lab value show the normal range, so you are judging how far off the value is and what it does, not recalling a range.

Common traps on prioritization items

• Choosing the sickest-sounding diagnosis instead of the most unstable client right now.
• Picking the client with the most abnormal-looking number when that number is expected for the condition.
• Calling the provider before doing what the nurse can do now, such as stopping a transfusion or positioning the airway.
• Assessing again when the stem already gives enough data to act.
• Letting a psychosocial option win when a physiological need is present, or ignoring a real safety threat because it sounds psychosocial.

Prioritization sits in Management of Care, the largest area of the NCLEX-RN, and the same reasoning drives the Prioritize Hypotheses and Take Action steps of every case study. The Prioritization and Delegation One-Pager puts these rules on one page.