NCLEX prioritization frameworks: how to decide who and what comes first

Start by reading what the question really asks

Look for the words that define the task: first, priority, most urgent, immediate, best, initial. Then decide whether you are choosing between clients, between actions for one client or between tasks you could delegate.

The same facts can have a different answer depending on what is being asked, so name the task before you name the answer.

Airway, breathing, circulation

When life-threatening problems compete, address airway first, then breathing, then circulation. This is the most familiar framework and it applies when a client is unstable or when the options include a threat to oxygenation.

It is not the answer to every question. If nobody has an airway, breathing or circulation problem, move to another framework instead of stretching this one.

Maslow and physiological needs

Maslow's hierarchy ranks needs from basic physiological requirements to safety and then to higher needs. Use it when the options are about different kinds of needs, and the answer is usually the most basic unmet one.

Used together with airway, breathing and circulation, it helps when two options both look physiological.

Acute before chronic, unstable before stable

A new, sudden or worsening problem usually comes before a long-standing one. A client whose condition is changing usually comes before a client whose condition is stable and expected.

Watch for the trap of choosing the client with the most dramatic diagnosis rather than the one whose condition is actually changing now.

The nursing process and safety

Assess before you intervene, unless the situation is an emergency. When the options include both a question you could ask and an action you could take, the assessment often comes first.

Among interventions, prefer the one that is least invasive and safest and that addresses the problem directly. Check that the option is within your scope and that it does not delay care for an unstable client.

• Assess, then plan, then act, then evaluate.
• Choose the least invasive effective action.
• Identify an actual problem before a potential one.
• Report and document, but not before addressing an urgent need.

Delegation and assignment

Some prioritization questions are really about who should do a task. In general, stable clients with predictable needs and routine tasks can be delegated to appropriately trained team members, while assessment, teaching, evaluation and unstable clients stay with the nurse who holds the responsibility.

Scope of practice varies by role and by state, so learn the rules that apply to your license level and check them with your board.

• Ask who is qualified to do this task for this client.
• Keep unstable or unpredictable situations with the nurse.
• Do not delegate nursing judgment.
• Remember that you stay accountable for what you delegate.