NURSING 101 Exit and NCLEX Examination Study Guide

Priorty Definition Deciding which needs or problems require immediate action and which ones could be delayed until later time because they are not urgent Guidelines for prioritizing  Nurse and client rank client’s needs  Priorities are classified as high, intermediate, or low  High priorities include life-threatening needs  Nonemergency and non–life-threatening needs are intermediate  Client needs not directly related to client’s illness or prognosis are low priorities Setting priorities for client teaching Review learning objectives established and determine what client perceives as important Prioritizing for groups of clients  Identify problem of each client, reviewing all nursing diagnoses  Determine most urgent needs and begin with those; then move to less urgent needs  Factor in time it may take to care for priority needs of each client  Involve client as much as possible in his or her care Key words First, Priority, Initial, Main Concern, Primary, first ,Best ,Most important, Essential, 3 Clients problems that usually indicate priority  Fresh postoperative clients ( newly arrived on nursing unit from postanesthesia care  Clients whose status has deteriorated from baseline (vital signs, level of consciousness,  Clients exhibiting signs of shock (hypovolemic, hemorrhagic, cardiogenic, distributive)  Clients who have allergic reactions  Clients who have chest pain  Clients who have returned from diagnostic procedures and require temporary, more intensive monitoring, including assessing for complications  Clients who verbalize unexpected or unusual symptoms (such as new or suddenly increased acute pain, blurred vision, sudden weakness or paralysis)  Clients who have equipment or tubing malfunction or accident (such as disconnection of IV line, central line, chest tube; or alarms ringing on mechanical ventilator or cardiac monitor)  Lower priority clients are often those whose main needs include teaching, which is not as time bound unless individual circumstances indicate otherwise  New Admission  MOST UNSTABLE PATIENT ALWAYS GOES FIRST  Injuries to face, neck and chest that impairs respiration are the highest priorities  Actual problems or needs have higher priority than potential problems or needs  Problems or needs identified by client are of a higher priority PRIORITY –WHICH PATIENT IS GOING DIE FIRST MNEMONIC TO REMEMBER HOW TO ADDRESS PRIORITY PHAN P=PRIORITY H= HIERARCHY (MASLOW) A= ABC’s N=Nursing process-(always as