1.2 Client Prioritization, Triage & SBAR Communication
Apply clinical prioritization frameworks (ABCs, Systemic vs Local, Acute vs Chronic, Maslow) and standardized SBAR handover to identify the most urgent client.
🎯 Key NCLEX-RN® Clinical Takeaways
- Airway, Breathing, and Circulation (ABCs) supersede all other physiological needs.
- Acute, changing, or unexpected clinical signs take priority over chronic, stable, or expected disease manifestations.
- Systemic complications (septic shock, acidosis) take precedence over localized problems (pain at surgical site).
- SBAR provides standardized interprofessional communication: Situation, Background, Assessment, Recommendation.
Prioritization requires ranking client needs based on clinical urgency and potential for rapid deterioration. The NCSBN Clinical Judgment Measurement Model emphasizes recognizing cues and prioritizing hypotheses.
The ABC framework dictates that airway compromise (stridor, foreign body, laryngeal edema) is the highest priority, followed by breathing (respiratory rate, work of breathing, cyanosis), then circulation (hypotension, hemorrhage, tachycardia).
When evaluating four clients on shift handoff, look for acute, unexpected changes rather than chronic, anticipated disease states. A client post-thyroidectomy with stridor is in immediate danger of asphyxiation and must be seen before a stable diabetic with hyperglycemia.
⚠️ Common Pearson VUE / NCLEX Traps
- Prioritizing severe chronic pain over subtle airway compromise (e.g. stridor, restlessness).
- Prioritizing an expected chronic abnormal finding (e.g. SpO2 90% in COPD) over an acute sudden change.
Knowledge Checkpoint
The medical-surgical charge nurse receives bedside reports on four newly admitted clients. Which client should the nurse assess first?