Which client should the nurse see first?
NCLEX-RN topic: Establishing priorities
- Airway, breathing and circulation come first.
- Then follow Maslow: physiological needs, then safety, then emotional needs.
- Acute beats chronic, actual beats potential, unexpected beats expected.
- Routine tasks wait when a client has a critical need.
- A new critical lab means reprioritize and call the provider.
Key facts
- Maslow's hierarchy puts physiological needs (oxygen, fluids, food, elimination) first, then safety, then love and belonging, esteem and self-actualization.
- Airway, breathing and circulation (ABCs) rank first among physiological needs.
- CURE sorts needs as Critical (act now: chest pain, respiratory distress, airway compromise), Urgent (discomfort or a significant safety risk), Routine (scheduled care) and Extras (comfort that is not essential).
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- An acute problem usually comes before a chronic one, because the body has not had time to adapt.
- An unexpected finding for the client's condition comes before an expected one, and an actual problem usually comes before a potential one.
- A new critical lab result, such as a hemoglobin of 6.9 g/dL (normal 13.8–17.2 g/dL for males, 12.1–15.1 g/dL for females), is a cue to reprioritize and call the provider.
- Acuity is how sick a client is; intensity is how much nursing time the client's care takes.
Quick check1 question · 2 more at the end
After handoff report, the nurse reviews four assigned clients. Which client should the nurse see first?
Correct answer: B.
Use the ABCs and the CURE levels. New chest pain with faster breathing is a critical need that threatens breathing and circulation, so this client is seen first. The client who needs the bathroom is urgent (a safety risk) and can be helped by a teammate, while chronic pain and discharge teaching are routine.
A Incorrect: chronic pain at a moderate level is a routine need; the body has adapted to this long-standing problem.
B Correct: new chest pain with increased work of breathing is a critical need under the ABCs and must be assessed now.
C Incorrect: this is an urgent safety need (fall risk), but it ranks below a critical breathing and circulation problem; the nurse can send a teammate to help.
D Incorrect: discharge teaching for a stable client is routine care that can wait until critical needs are met.
Full lesson
Each part starts with its main idea. Open a part when you want the details.
The short answer: See first the client whose airway, breathing or circulation is threatened, because those needs threaten life fastest. Next come other physiological needs, then safety, then emotional and esteem needs. Among similar clients, choose acute over chronic, actual over potential, and unexpected over expected findings. Routine tasks and comfort extras wait until critical and urgent needs are met.
1 Why does the client with an airway or breathing problem come first?Airway, breathing and circulation come first because without them nothing else you do matters. 1 min
Airway, breathing and circulation come first because without them nothing else you do matters. This is the ABCs rule, and it sits inside the base of Maslow's hierarchy.
Maslow ranks needs from the bottom up. Physiological needs (oxygen, fluids, food, elimination, sleep) come before safety (such as fall prevention), which comes before love and belonging, then esteem and self-actualization. If a bleeding, dehydrated client is also upset about a missing relative, stop the bleeding and replace fluids first.
2 How do you sort many needs into an order?The CURE levels turn a long to-do list into four clear tiers. 1 min
The CURE levels turn a long to-do list into four clear tiers. Use them when several clients all have physical needs.
| Level | What it means | Example |
|---|---|---|
| Critical | Needs action now to prevent decline | New chest pain, breathlessness, airway compromise |
| Urgent | Causes discomfort or a significant safety risk | Weak client on a bed alarm who must void now |
| Routine | Typical scheduled care | Morning medications, planned assessments |
| Extras | Comfort that is nice but not essential | Washing hair, a back rub |
Routine work never outranks critical or urgent needs. Morning medications can wait if a client suddenly develops chest pain.
3 Which data cues break a tie between two clients?When two clients look similar, compare their data cues. 1 min
When two clients look similar, compare their data cues. Data cues are pieces of clinical information that point to a change in condition.
- Acute over chronic. A sudden problem gets priority because the body has not adapted. New appendicitis pain beats long-standing arthritis pain.
- Actual over potential. A problem happening now usually beats a risk. Worsening shortness of breath beats a risk for skin breakdown.
- Unexpected over expected. Ask whether the finding fits the client's condition. Fever and cough are expected in a client being treated for pneumonia but unexpected in a client admitted after a fall, so that client is checked first.
- Changes from baseline. Compare with the handoff report and the chart. A heart rate in the 60s all week that is now over 100 is a red flag.
- New results. A newly reported critical lab means you reprioritize and call the provider. An example is a hemoglobin of 6.9 g/dL (normal 13.8–17.2 g/dL for males, 12.1–15.1 g/dL for females).
4 How do acuity and intensity differ?Acuity tells you how sick a client is, while intensity tells you how long their care takes. 1 min
Acuity tells you how sick a client is, while intensity tells you how long their care takes. A high-acuity client may have unstable vital signs, high-risk IV drugs or uncontrolled pain, and needs frequent assessment.
A high-intensity client needs a lot of time, for example help with every activity of daily living or long teaching sessions. Units use acuity scores to share work fairly. For "who first" questions, acuity points you toward the sicker client.
5 What the nurse doesThe nurse plans the shift right after handoff and keeps re-sorting as new cues arrive. 1 min
The nurse plans the shift right after handoff and keeps re-sorting as new cues arrive. A simple routine:
- After handoff, rank your clients by ABCs, then Maslow, then CURE.
- See the unstable client first and send help to the urgent one, for example asking a teammate to assist the client who needs the bathroom.
- Use the team. Stable, routine care can go to the right team member so you can stay with the critical client.
- Re-prioritize on every new cue, such as a call light, a lab call or a change from baseline.
Common mistakes
The traps students fall into most. Read these before you practice.
Watch out: Scheduled medications can be late when a client develops chest pain; routine tasks do not outrank critical needs.
Watch out: Emotional needs matter, but they come after physiological needs such as bleeding or poor fluid intake, not before.
Watch out: Fever and cough are expected in a client being treated for pneumonia but unexpected in a client admitted after a fall; the unexpected finding gets priority, not the diagnosis that sounds worse.
Watch out: Discharge teaching for a stable client waits when a critical lab arrives for another client, not the other way around.
Watch out: A high-intensity client takes a lot of time, but a high-acuity client is the sicker one.
How to remember it
Memory hook: "ABC, then Maslow, then CURE, then cues." Walk down that ladder until one client clearly stands out.
Self-check:
- Rank these: client asking for a hair wash, client with new breathlessness, client due for 0900 pills.
- Explain why fever means more in one client than another.
- Say what you do the moment the lab calls with a critical value.