03.05 Priority

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Okay, Priority Questions. Now, this is one of the areas that you need to understand the most as a nurse is how to set priorities. Not only is this gonna be really helpful as you take nursing exams, as you take the NCLEX, but it’s gonna help tremendously when you begin working on the floor. If you know how to set priority as a nurse, and you have to determine what’s most important at any given time, you’re gonna be much more effective as a nurse, you’re gonna be much more in taking care of your patients. So, I really wanna spend a lot of time talking about this and talking about how to determine what’s most important. Now, these questions are going to annoy you to death as you’re taking them on the NCLEX. Now, as a nurse, it’s really all about priorities. You have 10 million task, 10 million things that all need to be done at once. So, your job really becomes how to identify which of these must be done first? So we say they all need to be done at once but which one needs to be done first? Now, as you guys know, the NCLEX is based entirely of something called the Bloom’s Taxonomy. With Analysis, Application questions being at the very top, being the most highest level of cognitive domain, highest level of understanding a concept. These priority questions really fall in there. And it’s just critical that you learn this, okay. So, we’re gonna spend some time on this. We’re gonna help you understand what’s going on here.
 
First, I wanna talk to you about how you know a question is a priority question. What are some dead giveaways to help you determine that you’re gonna be dealing with a priority question and to use this kind of framework for selecting the answer? You might hear things like priority. Which patient is a priority? What’s the nurse’s priority? You might hear something in the question stem about you’re working in the emergency room. Or, a patient arrives via ambulance. Or a patient’s returning to the floor after a surgery, patient’s returning to the floor after a CT scan. You know, initial assessment on somebody. So, that’s really gonna be priority. You might hear something like what’s the most important? Which patient should the nurse see first? So, if you see these types of keywords in your stem, you’re dealing with priority question and we need to use this framework. So, when we talk priorities, we’re all about discussing Maslow’s hierarchy of needs and ABCs. Okay, with Maslow’s Hierarchy of Needs, what Maslow really did is he outline everything that a human needs to survive. Okay, everything from breathing, food, all the way up to creativity, spontaneity, ability to solve problems, and things like that. That’s kind of everything that a human needs to exist. From our basic physiological needs, all the way up to self-actualization. And according to Maslow, we can’t achieve this other higher level until we’ve completely satisfied a lower level. So, I can’t really worry about friendship and family unless I’m breathing and I have food. Okay, I can’t really think about or worry about creativity being creative if I don’t have health. Alright, so, that’s really important and it really all comes down to our ABCs. Without these, we can’t live.
 
So, let’s outline what’s your priority? What’s your most important thing to do as a nurse? The first thing is gonna be our ABCs, okay. And you can see here on ABCs, what I’ve done is I’ve left a little S here on our ABCs. That ‘s’ is going to stand for safety, okay. We have our ABCs, our Airway, Breathing, Circulation, and Safety. With airway being number 1, this is the very first thing that we have to take care of as a nurse. If our airways is not taken care, we can’t do anything else. If our airways are all good, then the next thing we worry about is our breathing. Okay, once our breathing is taken care of, we can worry about circulation. If circulation is all good, we can worry about safety. And that’s really how we need to work through these types of questions. Airway, breathing, circulation, safety. Okay, now, once all those are settled, we can start worrying about our patient’s pain, okay. How is their pain doing? What’s their pain rating? And let’s deal with that. But until we’ve established an airway, we have good breathing, our circulation is set, our patient is safe, we can’t really worry about pain. After that, we’re gonna worry about education. Okay, we’re worried about teaching our patient. And then, from there, we’re gonna learn more about or deal with more about their feelings. Okay, their psychosocial needs. Now, I know in nursing school, right, in your Fundamentals course, all they really talk about is this down here. Okay, they’re gonna talk about your patient’s feelings. That’s all that matters. Take care of your patient’s needs, your feelings, take care of their psychosocial needs. Well, that’s all important, okay? I get it. I get that that’s all important. We need to learn how to talk to our patients, of course. But, each of these things here comes way before dealing with our patient’s feelings. Okay, now, think about it this way. Think about how hard it’s going to teach a patient with a broken femur. Okay, just imagine a patient coming into the emergency room with a broken femur that happened from jumping out of the trampoline. Now, that’s not the time to teach your patient about how to take their pain meds or about how to safely jump on a trampoline. We have to deal with their pain first. Okay, and until we dealt with that pain issue, we’re not gonna be educating them. Or, okay for example let’s say, your patient, you have a question, you know, your patient is frustrated about their meal tray but they’re SpO2 is at an 82. Okay, are we worried about the temperature of their mash potatoes when their SpO2 is at an 82? No. We need to deal with that first before we can move on. Airway, Breathing, Circulation, Safety. Then, we deal with pain, education and feelings. Now, we have a lot of notes here. You guys, a lot of these is gonna be in the cheat sheet section, so make sure you get that as well. But I really want you to think in this hierarchy and whatever answer option is closest to airways is the one you’re gonna select. If you have answer options dealing couple with feelings, one with pain, a safety one and then an airway one, you deal the airway. But they are maybe gonna always be that obvious.
 
So, I wanna show you a couple of keywords and a couple of ways that you can determine which one of the ABCs you’re patient is dealing with. Things like the feelings, things like the pain, things like the education should be a little bit easier to spot. And if you’re dealing with like an airway problem, and a feelings problem, well, that’s pretty easy to understand. Where these questions get really difficult is when you’re dealing with an ABC and an S problem, an airway breathing circulation safety problem. Or, an airway and 3 breathing problems. So, what I’m gonna do here is I wanna give you a couple of keywords and ways that you can identify which kind of problem your patient is having. And so, that will help you pick which one is the highest priority. So, airway problems, some ways we’re gonna see airway problems are things like npo, gag reflex, breathing, water after surgery, dysphagia after stroke, or they might just flat out, say, airway. Does our patient have a patent airway? Do they have an open airway where they can ventilate, where they can get oxygen in. If we don’t have that, we can’t do anything else. Okay, so, we always deal with making sure a patient has a patent airway first. Always number one, things like gag reflex, breathing, those are ways we’re gonna see that they have that open airway. Now, breathing, things like breath sounds, O2 administration, pulse ox status, raising the head of bed, incentive spirometry. Is the patient actually breathing? We’ve established their patent airway, we got a patent airway, we have an open passage way for them to ventilate. Now, are they actually getting that air in? That’s what’s breathing is gonna be. Alright now, circulation, you have the obvious ones. The things like heart rate, blood pressure, CPR, fluid status, things like fluid deficit or overload. So, anything like diarrhea, vomiting, what are their pulses? They have bounding pulses, they have weak thready pulses. Okay, what’s the status of their fluid volume? IV fluids. What IV fluids are they giving? TPN, Total Parenteral Nutrition. Remember, that can add a significant amount of fluid to them everyday. Central lines, what are they getting through their central lines? Are they getting a bolus through there? Are they getting in drips? How much fluid is coming in on patients that are like renal type patients. We have to monitor that kind of thing very very very closely even if we’re just dealing with a drip, a very slow like dobutamine drip, or something. We have to watch that very closely. Bleeding and hemorrhage. Is the patient actively bleeding? That’s a circulation problem.
 
Now, safety problems. I want to divide safety up into 2 different sections. We got physical safety and we got infection safety. Okay, so, for our physical safety, especially this will come into play a lot in many things, even like our medication administration, things like that. But, where you might see this often, where maybe it’s tripped up a little bit here are in instances like dementia patients and things like that. So, for our physical safety, are there rugs, night lights, phone, have they just fallen, are they trying to walk after taking a narcotic? Okay, are they trying to get up after taking a narcotic? Are they taking too much narcotics? You know, evaluating our circulation with the safety of giving them additional narcotics possibly. Infection, have we assessed the infection? What’s the temperature? Are we conducting hand washing? Have we run cultures, antibiotics, wounds and drainage? So, what you really do when you get one of these questions guys, and what I really want you to do with this is to look at all your answer options. Okay, and say, okay, I got one talking about their pulse ox is 82. But, you know, they have some food lounge in their airway. What’s the most important? Okay, well, you know, getting that out and opening that airway needs to happen first. You know, we have a patient who just has a narcotics and wanna wonder around but their blood pressure is, you know, 75/42. You know, so, we really have to deal with those types of issues first. When you get these answer options, you get multiple options, I want you to lay them out in order of which ones comes closest to ABCs, okay? Now, if you get ones that are obvious like education, pain, but you have ones that are obviously airway, whatever option is closest to airway, wins, every time, okay. No question about that. Now, when you get these priority questions, sometimes, you might get an option that says you should call the provider. Let me outline for you when you should call the provider. This can be really tricky because we’ll get these difficult questions and you’re like “shoot, I don’t know what to do. I don’t have a clue, you know. I’ll just call the doctor” Okay, that’s good to call the doctor. But is it the very first thing that you should be doing? So, this is how you determine if you should be calling the doctor. Does the patient have an immediate significant need that I need to address before leaving the room? Is there an airway issue? Can I raise the head of the bed? Are they hemorrhaging? Can I put pressure on bleeding? Have they just fallen? Can I get them back to safety? Before I go and call the doctor, is there something absolutely immediate that lies within the nursing scope of responsibilities that I can do before I leave the room? And you have to do those things first. Don’t run off and call the doctor if there’s an airway issue, if there’s something that you can do. Okay, the minute you get a potassium level of, you know, let’s say, 6.1. Don’t go call the doctor until you’ve assessed, until you’ve checked it out, until you looked at their heart rhythm, ‘til you’ve asked them if they’re having chest pain, okay? That’s your priority, is what can be done in that moment for this patient before you go call the doctor or the provider. Alright, I hope that’s helping a little bit. I hope that’s making a kinda click.
 
Let’s do an example. And this one’s a little bit tricky here because we aren’t dealing with an ABC type of issue. So, the question here says, “What should be the nurse’s first action before administering an enema?” So, we can see here, that the question states what should be our first action? Okay, so, we see ‘first’ we know we’re dealing with a priority question. What should be the first action? Alright, so, this is a priority question. Number 1, verify the physician order. Number 2, collect the appropriate equipment. Number 3, arrange for the bathroom to be empty. Number 4, inform the patient about the procedure. So, what we need to do, we know this is a priority question that says, what should be our first action? Okay, what should we do first? So, what we need to do guys, let’s assign what each of these things are, okay. Let’s give it an ABC as pain, education, feelings, assign to each of these. Now, the tricky thing here too is guys, each of these things must be done before giving a patient an enema. So, let’s outline which ones we should do first. So, what is verify the physician’s order? Okay, that’s really a safety issue. Number 2, collect the appropriate equipment, that’s really implementation, that’s kinda like nursing process. Number 3, arrange for the bathroom to be empty, that’s really talking about kinda like psychosocial needs, feelings, okay. So, I’m just gonna give that a little ‘F’ right there. You know, giving him privacy to allow, you know, for pyschosocial needs to be met. Number 4, inform the patient about the procedure. Inform, we know that is an education one. So, which one of these options lies closest to our ABCs, okay? And then, we have pain, education, feelings. So, we have one education, we have one feelings one, we have one implementation one that would really fall somewhere in here in educate. And then we have a safety one. Verify the physician’s order. So, before we do anything else with this enema, we need to verify the order, make sure it’s signed, make sure it’s in there, make sure it’s correct, right patient, right procedure, right time, right everything, before we do anything else. That’s our safety one, that’s the closest one to our ABCs. Okay, it’s our safety issue with this. So, even if it’s not completely obvious, even if you don’t have a clear airway issue, line it up and select the one that comes closest to airway. If you have ones that are all ABCs, really divide them out. Okay, use your chart here and really divide them out and say, okay, which one is an airway one? Which one is a breathing one? Which one is a circulation one? And if I have one that’s an airway one, boom, that is your correct answer. Okay, that is your correct answer. Now, that’s how they’re really gonna be written a lot of times. Once they start getting to the really difficult questions are gonna be all ABC type of things. You know, a patient who has a blood pressure of 40/10, but who’s breathing at 2 respirations a minute.What thing are you gonna address first? Well let’s fix their airway, make sure there’s breathing and then we can fix their blood pressure, okay? And like I said, if they’re not talking about ABCs and all, that’s fine. Is it appropriate time to deal with their feelings or there’s something else, there’s some higher need need to be met before I can deal with their feelings?
 
Alright, you guys, I hope that helps. I want you to come back and watch this one a few times, read the text, check the cheat sheets. This is the one thing that I think if you understand this the best, this the most, complete, this is gonna help you the most in your career as a nurse. It’s gonna help you most on test. But most importantly, like I said, it’s gonna help you most in your career as a nurse determining what to do. Some days, questions can seem really ridiculous, you know, when it’s like you have 3 million patients and they all have 40,000 orders, what do you do first? That can kinda happen, you guys. That can kinda happen when you just get very difficult patients, very difficult assignment and you have so many things that need to be done, you have to outline what needs to be done first and you have to be realistic about what you can do and what needs to be done first. Alright guys, so that’s how you kinda set priorities, that’s how you answer priority questions, and I really hope that one helps you out.

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  • Question 1 of 10

The nurse is beginning a shift and has just received report from the off-going nurse. Of the following clients, which client must be assessed first?

  • Question 2 of 10

A nurse is assigned to four clients in the emergency room and knows to see which client first?

  • Question 3 of 10

The following four clients are in the emergency room and need to be seen by the nurse. The nurse would correctly prioritize which client first?

  • Question 4 of 10

A nurse is caring for a client with a new tracheostomy. The client has pneumonia with a WBC count of 4.6 x 10^9/L and is receiving morphine for pain control. Which of the following precautions is the priority at this time?

  • Question 5 of 10

The following four clients have presented to the emergency department. Which client should be seen first?

  • Question 6 of 10

The following clients are in the waiting room. Which client should be assessed and treated first?

  • Question 7 of 10

A nurse is triaging clients in the emergency department. Which of the following clients should be seen first?

  • Question 8 of 10

A pediatric nurse is working at an urgent care clinic. Which of the following clients should be assessed first?

  • Question 9 of 10

A nurse is working in a rehabilitation facility, and must assess 4 clients. Which of the following clients should the nurse see first?

  • Question 10 of 10

The nurse is caring for 4 clients. Which of the following clients should the nurse see first?