NCLEX Priority Setting — Which Patient Do You See First?

Priority assessment follows the ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy of needs. Physiological needs come first, and within physiological needs, airway and breathing concerns take priority. The client with new-onset shortness of breath and O2 saturation of 88% has an acute respiratory problem that could rapidly deteriorate — this is the highest priority. Normal O2 saturation is 95% or higher; 88% indicates significant hypoxemia. The postoperative client with 6/10 pain needs assessment and intervention but is not in immediate physiological distress. Routine IV antibiotics and a chronic pain request can wait several minutes. NCLEX priority questions consistently test the ability to recognize which client is most unstable; airway and breathing issues almost always come before bleeding, pain, anxiety, and elimination concerns.

The chain of command is the hierarchical structure used to escalate clinical concerns when standard channels do not resolve them. Proper sequence: bring the concern to the immediate supervisor first (charge nurse), then to the nurse manager, then to higher administrative or medical authorities (nursing supervisor, attending physician, chief medical officer, ethics committee) as needed. The nurse should document each step and the response. Using the chain of command appropriately: addresses concerns about unsafe care without bypassing legitimate authority; protects the nurse who must justify their actions; ensures patient safety. The nurse is professionally and legally obligated to advocate for patient safety even when this means escalating against a physician's order. Refusing to speak to the physician or discussing concerns publicly are inappropriate.

Delegation to UAPs (CNAs, patient care techs) follows the 'Five Rights of Delegation' from the NCSBN: right task, right circumstances, right person, right direction/communication, right supervision. UAPs can perform routine, repetitive tasks for stable clients — bathing, feeding, ambulating, vital signs on stable clients, ADL assistance, simple measurements, transport. UAPs cannot perform tasks that require nursing judgment: assessment, teaching, evaluation of effectiveness, interpretation of data, medication administration (in most states), or care of unstable clients. The RN remains accountable for the outcomes even when tasks are delegated. Initial assessment and teaching require nursing judgment and are RN tasks. Evaluating medication effectiveness requires interpreting whether the pain is controlled, which is nursing judgment. Routine vital signs on a stable client is the appropriate delegation.

LPN scope of practice varies by state but generally includes: administering oral, IM, and subcutaneous medications; reinforcing teaching done by the RN (not initial teaching); performing routine dressing changes; collecting data (but not initial comprehensive assessment in most states); providing basic care; tracheostomy care and suctioning in some states. LPNs cannot: perform initial assessments (RN role); develop the care plan (RN role); administer IV push medications in most states (some states allow with certification); make discharge teaching the primary educator (RN reinforces). The RN delegates tasks within the LPN's scope and supervises. Administering oral medications and reinforcing teaching are clearly within LPN scope. The RN does the initial assessment and develops the plan; the LPN implements parts of the plan with the RN's direction.

A DNR order specifically directs that CPR (chest compressions, defibrillation, intubation, advanced cardiac medications) will not be performed if the client experiences cardiac or respiratory arrest. The order does NOT mean: no treatment at all (the client continues to receive all other ordered treatments — antibiotics, IV fluids, pain management, comfort care); no nursing care; no medical attention. DNR is specific to resuscitation. Other related orders include: DNI (Do Not Intubate); AND (Allow Natural Death); POLST/MOLST (Physician/Medical Orders for Life-Sustaining Treatment, a more comprehensive form); 'comfort measures only' or 'comfort care' orders. The nurse must understand the specific scope of the order and continue to provide all care within those limits. Discussion of advance directives is required upon hospital admission under the Patient Self-Determination Act.

A durable power of attorney for healthcare (also called a healthcare proxy or healthcare surrogate) is a legal document in which a competent adult designates another person to make healthcare decisions if the client becomes incapacitated and unable to make decisions themselves. The 'durable' aspect means it remains in effect during the client's incapacity. The designated proxy should: know the client's wishes and values; be willing to advocate per those wishes; be available and engaged when needed. The proxy operates based on either: substituted judgment (what the client would have wanted) or best interest (what is in the client's best interest if their wishes are unknown). A living will documents the client's specific treatment preferences, while the healthcare proxy designates a decision-maker. Together they form advance directives. The nurse documents whether the client has advance directives and ensures documentation is in the chart.

Hand hygiene is the single most important intervention to prevent healthcare-associated infections (HAIs). CDC guidelines specify when to perform hand hygiene: before patient contact, before aseptic procedures, after body fluid exposure risk, after patient contact, and after contact with patient surroundings (the 'Five Moments' from WHO). Alcohol-based hand rubs are preferred for routine hand hygiene; soap and water is required when hands are visibly soiled or after caring for clients with C. difficile (the spores resist alcohol). Hand hygiene is more important than glove use — gloves are an addition, not a substitute. Hands must be cleaned before donning gloves and after removing them. Despite being simple and effective, hand hygiene compliance among healthcare workers is often poor (around 40-60%), making education and observation critical. Nurses model hand hygiene for other staff.

Airborne precautions are required for diseases transmitted by small droplet nuclei (under 5 microns) that remain suspended in the air for extended periods. Examples: tuberculosis (TB), measles, varicella (chickenpox), disseminated zoster. Requirements: (1) Private negative-pressure room (Airborne Infection Isolation Room or AIIR) with negative airflow and HEPA filtration or external venting; (2) N95 or higher respirator (fit-tested) for all caregivers; (3) Mask on the client during transport outside the room; (4) Door kept closed at all times. Droplet precautions are for larger droplets (greater than 5 microns) that travel only 3-6 feet: surgical mask within 3 feet of client; examples include influenza, pertussis, meningococcal disease. Contact precautions are for transmission by direct or indirect contact: gowns and gloves for room entry; examples include C. diff, MRSA, VRE. Standard precautions apply to all clients regardless of diagnosis.

The traditional 'Five Rights' of medication administration are right patient, right medication, right dose, right route, right time. Modern practice has added: right documentation (chart immediately after administration, not before), right reason (the medication should be appropriate for the indication), right response (assess the client's response to determine effectiveness), right to refuse (the client has the right to decline). Verifying the rights requires multiple checks: read the medication label three times (when pulling from the cabinet, when preparing, before administering); use two patient identifiers (name and date of birth, with armband verification — not room number); compare the medication to the medication administration record (MAR); double-check high-alert medications (insulin, anticoagulants, narcotics) with another nurse. Medication errors are a major patient safety issue, and adherence to the rights is the primary defense.

Proper documentation correction maintains the legal integrity of the medical record. The correct procedure: draw a single line through the incorrect entry so it remains readable; write 'error' or 'mistaken entry' near the line; initial and date the correction; make the correct entry. Never erase, white out, scribble out, or remove pages — these actions appear to hide information and undermine the record's credibility in any legal or regulatory review. The original entry must remain visible so the corrected information can be understood in context. Electronic health records have built-in correction protocols: corrections are usually visible with timestamps and the original entry remains accessible. Late entries (information remembered later) are added at the next available chronological space with a notation like 'late entry for [date/time]'. Honest, transparent correction protects both patient safety and nursing license.