Prioritizing, Delegation, and Assignment

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What should you DO FIRST?

What is the most important intervention or what should you do FIRST? Oh no! Some long reading! Please read.

What intervention/assessment should you DO FIRST? This is one of the most difficult questions on the NCLEX or any nursing test since most of the time all of the available choices are interventions/assessment that need to be done.  Let’s go through some rules that can help you choose the right answer:

  1. It is almost never call the doctor. Unless it is something like a potassium= 2.8 mEq/L and you need replacement orders or a patient has a new cast and toes feel cool to touch (perfusion is compromised).
  2. If they provide you with an assessment, likely the answer will be an intervention. For example, the most important intervention for a client with severe respiratory distress is to have the intubation tray at the bedside/have the client intubated, not assess the client. You were already told that the client is in respiratory distress.
  3. If you are told that the patient has a narcotic overdose, you know what is wrong, right? Now intervene. Give the patient some narcan. Don’t waste time checking pupils or listening to breath sounds. If the patient is not breathing due to the overdose, do you really think that Oxygen will help. 
  4. If they do not tell you the assessment of the problem, the answer may be assess FIRST. For example, a patient tells you that his or her arm is hurting.  You would need to assess first.  Choose assessment. You need to know what’s wrong FIRST! Why is the arm hurting. Is it swollen? Was it hurt?
  5. Always think! What is the most important thing I should do for the patient to save his life or solve his problem: An assessment or an intervention?
  6. Again, do you assess or do you intervene?…..mmmm..Well, are they telling you what’s wrong? Or do you need to find out?

Example: Your client has an opioid overdose. What action should you do first?

  1. Give Oxygen
  2. Give Narcan
  3. Assess Respiratory Status
  4. Check ABG
  1. The question reads: A client has an opioid overdose (heroin, morphine, or fentanyl). They have provided you with the assessment. You know what’s wrong.  Now choose the intervention: NARCAN/NALAXONE.  Do not choose assess respiratory status, give oxygen, or do an ABG. What is going to save your client’s life is to reverse opioid overdose with Narcan and nothing else. 
  2. You enter a client’s room who was given ativan IV (Lorazepam), a benzodiazepine, and now he has very shallow breathing. What should you do FIRST? You know he is overdosed with a benzodiazepine (an assessment). Choose an intervention that will save the patient’s life. Give flumazenil (Romazicon).

NCLEX Tip: flumazenil (romazicon) reversal agent for bendodiazepines and Narcan for opioid overdose. Know this!

Take the time to learn these antidotes

Warfarin (Coumadin)=Vitamin K

Heparin= Protamine Sulfate

Digoxin= digibind
digoxine immune fab

Tylenol overdose=Acetylcysteine (mucomyst)

Hyperkalemia when dialysis not available immediately= Insulin and Dextrose, Kayexalate, Calcium gluconate, Albuterol, or Sodium bicarbonate. 

Remembering the Treatments for hyperkalemia

If the question tells you what the problem is then choose an intervention.

If the question does not tell you the problem then choose an assessment.

Ask yourself: What would benefit the client the most?

What to do first if this happens.

Place client in left Trendelenberg 

Sit up in bed to decrease blood pressure. Check for bladder distension or fecal impaction.  Remove any noxious stimuli

Oxygen and Morphine always show up as choices. But you may also see nitroglycerin and aspirin.

Remember MONA- morphine, oxygen, nitroglyceirn and aspirin

Goal: Treat chest pain. Chest pain = myocardial ischemia/infarct

Assess for muscle weakness and check potassium levels.

Check potassium levels and digoxin levels. Hypokalemia potentiates digoxin toxicity.  If a client has visual disturbances (e.g., seeing halos) always think digoxin toxicity. Normal digoxin level is 0.8- 2.0 ng/mL

Too much antidiuretic hormone. Patient retains fluid. Patient is hyponatremic (dilution from too much fluid). Ok to give sodium to his client. Priority is to restrict fluid.

Have the external/transcutaneous pacemaker at the bedside

Priority is to stop the infusion.

Report black-colored stools= GI bleeding

Priority is to check breathing. Remember that paralysis/weakness starts from the lower extremities and moves up the body. The client will go into respiratory arrest/distress as the breathing muscles become weaker/paralyzed.

Bedrest. If the client is dehydrated the priority is to give fluids. I saw a question in Saunders. Patient was unstable and tachycardic and the answer was keep in bed. 

Check Blood sugar

Get intubation tray.  Any patient in respiratory distress, get ready to intubate is almost always the answer.

Watch for nephrotoxic drugs/antibiotics/Contrast dye

Watch for electrolyte imbalances, especially hyperkalemia

Have tracheostomy tray at the bedside in case of airway closure due post operative edema.

Check for hypocalcemia, even in thyroidectomies. The parathyroid may have been damaged during surgery. 

Two important signs of hypocalcemia: Chvostek’s and Trousseau’s sign

Let's practice your new knowledge!