Prioritization

© USMLE Galaxy LLC

1
NCLEX Question
The nurse is assessing a 4 year old who was sent to the ED from urgent care. Assessment reveals
tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs
are:
Temp: 39 C
HR: 188
RR: 46
O2: 82 %
Which of the following is the priority nursing action at this time?

a. Keep the child calm and call for emergency airway equipment
b. Obtain IV access
c. Assess the throat for a cherry red epiglottis
d. Place the child on a high flow nasal cannula at 100% FiO2

2
Answer: A
A is correct. Based on the presenting symptoms, the nurse suspects that this child has epiglottitis. Any child presenting with
excessive drooling, distress, and stridor is highly suspicious for this medical emergency. In addition, this client is already showing
signs of circulatory compromise including circumoral cyanosis and mottling. The priority nursing action in this emergency is keeping
the child calm and calling for emergency airway equipment. The child is at risk of losing their airway, and airway is always the
priority!

B is incorrect. It is inappropriate to attempt to obtain IV access on a child suspected of epiglottitis before emergency airway
equipment is available. The priority action at this time is keeping the child calm and calling for emergency airway equipment.

C is incorrect. It is inappropriate to assess the throat for a cherry red epiglottis at this time. Although presence of a cherry red
epiglottis would confirm the diagnosis of epiglottitis, this child is at risk of losing their airway. The priority action will be to protect
that airway before assessing the throat.

D is incorrect. Placing the child on a high flow nasal cannula at 100% FiO2 is not the priority at this time. This answer probably
sounded right, because you see the O2 is 82% and they have circumoral cyanosis. Oxygen sounds like the right answer! But this
intervention addresses the ‘C’ in your ABC’s - circulation. And the priority is always ‘A’, airway! This child is at risk of losing their
airway, so all interventions need to wait until there is emergency airway equipment close by. If anything upsets the child their airway
could spams and obstruct completely making it impossible to intubate them. That is why keeping the child calm and calling for
emergency airway equipment is the priority in epiglottitis clients.
NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Risk potential reduction

Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.

Subject: Pediatric
Lesson: Respiratory

NCLEX Question
Which of the following is the first nursing action for a client experiencing
dyspnea?
A. Remove pillows from under the client’s head
B. Elevate the head of the bed
C. Elevate the foot of the bed
D. Take the client’s blood pressure

3
Answer: B
Choice B is correct. Elevating the head of the bed allows the abdominal organs to descend, giving the
diaphragm more room and facilitating lung expansion. Dyspnea is difficult or labored breathing. A
dyspneic client usually has rapid, shallow respirations. Because of this "shallow" breathing, ventilation is
affected, and C02 accumulates. Dyspneic clients can often breathe better in an upright position. When
standing or sitting, gravity pulls the abdominal organs down and away from the diaphragm, creating
more space in the thoracic cavity. This allows the lungs more room for expansion and allows the client to
take more air with each breath (better ventilation).

Choices A, C, and D. None of these answer choices are appropriate as the first nursing action for a client
experiencing dyspnea. Recumbent positions (Choices A and C) limit expiratory flow and cause a
decrease in elastic recoil of the lung. Therefore, such positions do not improve ventilation. The nurse
should check the client's blood pressure (Choice D), but the priority action should be to position the client
to reduce breathlessness and the effort of breathing.

NCLEX Question
A client in septic shock in the intensive care unit is receiving a Dopamine infusion.
Upon assessment, the nurse notices that the client’s blood pressure is 195/120
mm Hg. Which initial nursing action would the nurse implement?

a. Discontinue dopamine
b. Notify the physician
c. Administer furosemide
d. Assess the client’s GCS

4
Priority toolkit:
● #1 - ABCs
○ Match symptoms to the ABCs + choose the highest ranking action
○ When in DISTRESS, don’t ASSESS!
○ If you can do something… don’t notify - do it!

5
 NCLEX Question
The nurse receives report on the following four clients. Which of the following
should she assess first?

a. A 27 year old admitted for an asthma flare up that is being discharged today
b. A client newly diagnosed with TIDM
c. A newly admitted 38 year old with a downtrending hemoglobin and most
recent level of 3.9
d. A client with COPD whose ABG results are pH: 7.25, CO2: 66, HCO3: 30

Answer: C
A is incorrect. This is the most stable client. They are preparing for discharge.

B is incorrect. This client is a new diagnosis and is the second client the nurse should prioritize.

C is correct. This is an acute client with critical lab values and a rapidly changing condition. They must be
assessed immediately

D is incorrect. This is a chronic client with expected findings.

6
NCLEX Question
A nurse is caring for a client receiving digoxin. The client’s most recent serum
digoxin level was 2.5 ng/mL. Which of the following priority nursing actions
should the nurse take? Select all that apply.

A. Withhold the client’s scheduled dose

B. Administer the dose as prescribed
C. Assess the client's urinary output
D. Assess the client's most recent sodium level
E. Assess the client’s heart rate and rhythm

Answer: A and E
The client’s digitalis level of 2.5 ng/mL is indicative of toxicity. Digoxin has a narrow therapeutic index, which
means it can cause significant side effects, such as cardiac arrhythmias (e.g., bradycardia, heart block, ventricular
arrhythmias), even at plasma concentrations only twice the therapeutic plasma concentration range. Normal
corrective serum digoxin levels range from 0.5 - 2 ng/mL. A level higher than 2 ng/mL is considered toxic. The
nurse is correct to withhold the scheduled dose (Choice A) and assess the client’s heart rate and rhythm (Choice
E) as the client is likely to be experiencing bradycardia.

Choice B, C, D, and F are incorrect. It would be wrong to administer the next dose, as this would exacerbate the
toxicity. An assessment of the urinary output and sodium is not relative to digitalis toxicity and is not the priority
here. Calling the physician to notify regarding the toxic level is appropriate, but there is no reason to obtain a 2D
echocardiogram. A 2D echocardiogram will not add any additional information at this point. Instead, an
electrocardiogram must be obtained to look for any rhythm disturbances due to digoxin toxicity.

7
Priority toolkit:
● #1 - ABCs
○ Match symptoms to the ABCs + choose the highest ranking action
○ If you can do something… don’t notify - do it!
● #2 - Spectrum of stability
○ Actions:
■ What is causing their instability? Prioritize the action that addresses it!
○ Clients:
■ Which client is most unstable? Look for keywords!

8
NCLEX Question
The nurse is caring for a client who intentionally overdosed on amitriptyline.
What action should the nurse prioritize?
A. Obtain a 12-lead electrocardiogram
B. Request a prescription to consult psychiatry
C. Determine the reasoning for the overdose
D. Establish a therapeutic relationship

Answer: A
A is correct. Obtaining a 12-lead electrocardiogram is the priority. Amitriptyline is a TCA and can cause
cardiac arrhythmias. If the client has overdosed on amitriptyline, they are at high risk for arrhythmias.
This is a physiological need and the nurse must prioritize this action first.
B is incorrect. Requesting a prescription to consult psychiatry is important, but not the priority. This
client has a physiological issue that must be addressed first.
C is incorrect. Determining the reasoning for the overdose will also be important, but will fall under the
safety category of the hierarchy of needs. The nurse should prioritize any physiological needs first, which
in this case includes the risk for cardiac arrhythmias.
D is incorrect. Establishing a therapeutic relationship falls under the love and belonging category of the
hierarchy of needs. The nurse should prioritize any physiological needs first, which in this case includes
the risk for cardiac arrhythmias.

9
NCLEX Question
The psychiatric nurse is providing care for a client who has just calmed down
after exhibiting inappropriate behaviors related to Bipolar disorder. The nurse
knows that which of the following is the best way to help prevent another
unseemly episode?

A. Identify the consequences of the behavior

B. Assist the client in understanding triggering events or feelings that may have
lead to the outburst
C. Ensure that the client’s safety is upheld
D. Offer the client clear options to deal with their current behavior

Answer: B
The correct answer is B. The psychiatric nurse would be most effective in preventing further
inappropriate episodes by assisting the client in understanding what may have triggered the
event.

Choice A is incorrect. Identifying the consequences of inappropriate behavior would be a more

appropriate intervention before the client’s response began escalating. Since this client is calm,
identifying values is not the most effective option to prevent recurring episodes.

Choice C is incorrect. Ensuring the client’s safety is intact is always a priority but is a more
appropriate action during the client’s episode of inappropriate behavior rather than while the
client is calm.

Choice D is incorrect. A client experiencing an episode of inappropriate behavior related to

bipolar disorder is unlikely to absorb client teaching. Teaching is best understood when the client
is calm and states readiness to learn.

10
Priority toolkit:
● #1 - ABCs
○ Match symptoms to the ABCs + choose the highest ranking action
○ If you can do something… don’t notify - do it!
● #2 - Spectrum of stability
○ Actions:
■ What is causing their instability? Prioritize the action that addresses it!
○ Clients:
■ Which client is most unstable? Look for keywords!
● #3 - Hierarchy of needs
○ Especially helpful in mental health questions
○ Read the question closely

11
NCLEX Question
A client who is 2-days postoperative from right femoral popliteal bypass surgery
complains of worsening right leg pain. Upon assessment, the RN notes swelling
and ecchymosis at the incision sites. Which action would be the nurse’s initial
priority?
A. Apply pressure to sites with sandbag
B. Palpate pedal pulses
C. Assess for signs of claudication
D. Apply warm compress to incision sites

Answer: B
Choice B is correct. The most significant complications this client is at risk for after the revascularization procedure are
thrombus, hemorrhage, infection, and arrhythmias. Mild to moderate swelling, bruising, and pain at the surgical site are
expected and typically resolve over time as the leaked blood is reabsorbed. The most important action would be to assess
the client’s pedal pulses (distal to incisions). If pulses are intact, the nurse would then address the client’s complaint of
worsening pain.

Choice A is incorrect. These symptoms are expected following this type of surgery. Manual pressure would be
appropriate if the client was actively bleeding.

Choice C is incorrect. Intermittent claudication is a cramp-like pain in the leg or buttock during activity due to poor blood
supply. This is a sign of arterial disease, but not of postoperative complication, and would not be a priority for this client.

Choice D is incorrect. The RN should perform a focused assessment to rule out potential complications before
implementing any interventions. Applying a warm compress may be helpful for reducing the client’s pain, but will also
result in vasodilation which may increase swelling.

12
NCLEX Question
The nurse looks up at the telemetry monitor and notes the following. What is
their priority nursing action:

A. Defibrillate the client

B. Assess the client
C. Call for help
D. Start chest compressions

Answer: B
A is incorrect. The nurse first needs to assess the client. If they client is in
asystole, chest compressions should be started. Defibrillation is not appropriate
for a client in asystole.

B is correct. The priority nursing action is to assess the client. It is possible the
client disconnected their leads, or the equipment has malfunctioned. Assess the
client first!

C is incorrect. A is incorrect. The nurse first needs to assess the client. If they
client is in asystole, THEN yell for help!

D is incorrect. The nurse first needs to assess the client. If they client is in
asystole, THEN chest compressions should be started.

13
Priority toolkit:
● #1 - ABCs
○ Match symptoms to the ABCs + choose the highest ranking action
○ When in DISTRESS, don’t ASSESS!
○ If you can do something… don’t notify - do it!
● #2 - Spectrum of stability
○ Actions:
■ What is causing their instability? Prioritize the action that addresses it!
○ Clients:
■ Which client is most unstable? Look for keywords!
● #3 - Hierarchy of needs
○ Especially helpful in mental health questions
○ Read the question closely
● #4 - Nursing process
○ Assess what correlates with the problem
○ Client comes before equipment!

14