Assessment before intervention (always assess FIRST unless emergency)
Collect data → analyze → plan → implement → evaluate
4. Acute vs. Chronic
New/acute problems before chronic/stable problems
Unstable before stable
Unexpected findings before expected findings
"Which Client to See FIRST?" Strategy
Eliminate clearly stable patients
Identify life-threatening situations (ABCs)
Look for unexpected vs. expected findings
Consider which situation will deteriorate fastest
Practice Examples
Q1: The nurse has four patients. Which should be assessed first?
A) Patient with stable angina requesting pain medication
B) Post-op patient with urine output of 20 mL/hr
C) Patient with COPD and SpO2 of 90%
D) Patient who fell and reports elbow pain
Answer: B: Low urine output (normal >30 mL/hr) indicates possible hypovolemia or renal compromise. SpO2 90% is expected baseline for COPD. Angina and elbow pain are concerning but not immediately life-threatening.
Q2: A patient is found unresponsive. The nurse should FIRST:
A) Call the rapid response team
B) Check for a pulse and breathing
C) Administer oxygen via nasal cannula
D) Review the patient's code status
Answer: B: Assessment first. Check responsiveness, then pulse and breathing to determine next steps.
Common Priority Traps
"Assess" vs "Intervene": Assess first UNLESS the situation is immediately life-threatening
Expected vs. Unexpected: SpO2 90% in COPD is expected; SpO2 90% post-op is NOT
"Notify the provider" is rarely first: Always assess and intervene within your scope first
Emotional needs matter but are lower priority: Physiological needs first