Prioritization & delegation: practice questions with explanations

1What priority questions ask

Many nursing exam questions, including NCLEX-style questions, ask which patient you see first, which action comes first or which task you can delegate. Often every option is something a good nurse would do. The question is about the order.

To answer, ask one question: what will harm this patient soonest if I do nothing? Then choose the option that deals with that threat, or the assessment that the next steps depend on.

Several frameworks help you decide. They do not compete; they are different lenses on the same idea:

• ABC: airway, then breathing, then circulation.
• Maslow’s hierarchy: physiological needs, then safety, then love and belonging, esteem and self-actualization.
• Acute before chronic, unstable before stable, actual before potential and unexpected before expected.
• The nursing process: assess before you act, unless the situation is an emergency.

2ABC, Maslow and the comparison rules

ABC. A blocked airway kills in minutes, so it comes first: stridor, swelling of the tongue or throat, gurgling, a new hoarse voice after neck surgery.

Breathing comes next: a very fast or very slow rate, accessory muscle use, falling SpO₂. Then circulation: bleeding, a falling blood pressure, a rising pulse, poor perfusion.

In cardiac arrest the order changes to C-A-B: compressions start at once, because blood flow to the brain has stopped.

Maslow. Physiological needs such as oxygen, fluids, nutrition and elimination come before safety, and safety comes before psychological needs. The exception is an immediate safety risk such as a patient with a suicide plan, which outranks a stable physical need.

Then compare the patients with these rules:

• Acute vs chronic. New slurred speech beats long-standing arthritis.
• Unstable vs stable. A blood pressure falling over the last hour beats a steady high one.
• Unexpected vs expected. Right shoulder pain after laparoscopy is expected; a black, tarry stool on heparin is not.
• Systemic vs local. Signs of sepsis beat a red area around a wound.
• Baseline. An SpO₂ of 90% in a COPD patient with a target of 88–92% is that patient’s normal.

3Delegation and assignment

Delegation gives a competent person the authority to do a selected task. The nurse who delegates stays accountable for the decision and for supervising it; the delegate is responsible for doing the task correctly.

Use the five rights of delegation:

1. Right task: routine, with a predictable outcome, and allowed for that role.
2. Right circumstance: the patient is stable and the setting is suitable.
3. Right person: the delegate is trained and competent for this task.
4. Right directions and communication: what to do, when, and exactly what to report.
5. Right supervision and evaluation: follow up, give feedback and check the result.

In general textbook terms, roles divide like this. Exact scope differs between states and countries, so follow local rules.

• Unlicensed assistive personnel (nursing assistants): hygiene, feeding without swallowing risk, moving and walking stable patients, routine vital signs, intake and output, weights, routine specimens.
• LPN/LVN: care of stable patients with predictable needs, many medications, dressings, catheters, data collection and reinforcing teaching.
• RN: assessment (especially the first), care planning, initial teaching, evaluation, unstable patients, triage and starting blood transfusions.

Assessment, teaching, evaluation and nursing judgement are never delegated to assistive personnel.

4Triage

Triage sorts patients by urgency, not by arrival time.

Emergency Severity Index (ESI), used in many emergency departments, has five levels:

• Level 1: needs an immediate life-saving intervention (for example, not breathing).
• Level 2: high-risk situation, new confusion or severe pain or distress (for example, chest pain).
• Levels 3–5 depend on the expected resources for a stable patient: two or more is level 3, one is level 4, none is level 5. Lab tests count as one resource, imaging as another.

Mass-casualty triage aims to do the most good for the most people. In START triage, walking victims are green (minor). For the rest, check breathing, perfusion and mental status:

• Not breathing after the airway is opened: black (deceased or expectant).
• Breathing over 30/min, no radial pulse or capillary refill over 2 seconds, or cannot follow simple commands: red (immediate).
• Passes all three checks but cannot walk: yellow (delayed).

5A worked example

Rank the patients yourself before opening each step.

6Common mistakes

• Choosing the patient with the most dramatic number instead of the one whose condition is changing.
• Treating an expected finding, such as a COPD patient within target, as an emergency.
• Calling the provider before assessing the patient when the situation is not yet clear.
• Delegating a task to an assistant because the patient is “only” having vital signs, when the patient is unstable.
• Forgetting that the nurse stays accountable after delegating.
• Using everyday triage in a disaster: in mass casualties, scarce resources go to those who can be saved.

7How exam questions look

• Easy (key terms and facts): the ABC order, Maslow’s levels, the five rights of delegation, triage colors and ESI levels.
• Medium (applying the concepts): which patient to see first among two or three, which right of delegation is missing, which task fits which role.
• Hard (cases and analysis): four patients with subtle findings, START decisions with a trap, unsafe orders and the chain of command, deciding what to delegate in a busy shift.

Read every option, cross out those that are stable or expected, and choose the threat that is acute, unexpected and closest to the airway.