"Which client do you see first?" is the most common — and most feared — question type on the NCLEX. The good news: the exam is not testing your instincts. It's testing whether you apply the same decision ladder every single time. Here is that ladder.
The Prioritization Ladder
1. ABCs: Airway, Breathing, Circulation
A threatened airway beats everything. Stridor, drooling, choking, an obstructed tracheostomy — these clients are seen first, full stop. Then breathing (falling oxygen, severe respiratory distress), then circulation (bleeding, shock-level blood pressures, lethal rhythms).
2. Acute beats chronic
A client with new chest pain outranks a client with chronic pain of the same score. New, sudden, and changing findings are the exam's favorite priority signal.
3. Unstable beats stable
Abnormal-and-worsening vitals, fresh post-op patients (first 12–24 hours), and anyone "not acting right" outrank stable clients with predictable needs.
4. Actual beats potential
A client who is hypoxic beats a client who is at risk for hypoxia. Maslow's hierarchy reinforces the same idea: physiological needs first, then safety, then psychosocial needs.
Delegation: Who Is Allowed to Do What?
| Team Member | Can Do | Cannot Do |
|---|---|---|
| RN | Assess, teach, evaluate, plan care, IV push meds, care for unstable clients | — (the RN owns clinical judgment) |
| LPN/LVN | Stable clients with predictable outcomes, most meds (not IV push), reinforcement teaching, sterile procedures | Initial assessments, care planning, unstable clients, IV push medications |
| UAP | Bathing, feeding, ambulation, intake/output, vital signs on stable clients, reporting observations | Anything requiring assessment, teaching, evaluation, or judgment |
Remember it as ATE: Assess, Teach, Evaluate — the three things you never delegate, in any state, to anyone.
Worked Example
The nurse receives report on four clients. Which client should the nurse assess first?
- A client awaiting discharge teaching
- A client with new-onset stridor and drooling
- A client requesting pain medication for pain rated 6/10
- A client whose IV pump alarm is sounding
Show answer & rationale
Answer: B. Stridor and drooling signal a threatened airway — the top of the ABC ladder. Discharge teaching is education (delayable), 6/10 pain is real but stable, and an alarming pump is equipment, not a deteriorating airway. Run every "see first" question through the ladder and the answer usually picks itself.
Frequently Asked Questions
How do I decide which patient to see first?
ABCs first, then acute over chronic, unstable over stable, actual over potential. Airway threats outrank everything.
What can a UAP do?
Routine care on stable clients — hygiene, feeding, ambulation, I&O, stable vitals. Never assess, teach, or evaluate (ATE stays with the RN).
Where does Maslow fit?
After ABC threats: physiological needs (oxygen, fluids, pain) before safety, and safety before psychosocial needs.
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