The Nurses’ Licensure Examination may contain questions in which may require you to use the prioritization of the nursing actions. In the Principle of Prioritization, one must look for the key words found in the question that indicate the need to prioritize.

Always remember, that when a question requires prioritization, all options can be correct and you must determine the correct order of actions. However, if you find an offending cause, eliminate the offending cause first.

In prioritization, one must use several processes in deducing the correct answer. Examples are:
  • Airway, Breathing, and Circulation (ABC)
  • Maslow’s Hierarchy of Needs (Physiological, Safety, Love and Belonging, Self-Esteem, Self-Actualization)
  • Nursing Process: Assessment, Diagnosis, Planning, Intervention, and Evaluation (ADPIE)
  • Rescue, Alarm, Confine, and Extinguish (RACE) in cases of fire
  • Airway, Breathing, Circulation, and Disability or Dysfunstion in some cases

Sample Question:

A patient is experiencing fever with a temperature of 38.4ºC. What priority nursing action is needed to be done?
  1. Assess the client for underlying conditions
  2. Administer Paracetamol 500mg, P.O.
  3. Give the client a Tepid Sponge Bath(TSB)
  4. Alert the attending physician of the clients condition

All of the choices are nursing actions, but one must focus on the priority action of the nurse which is to DECREASE the client’s elevated temperature. While some choices pertain to actions that may decrease the temperature, one particular choice emphasizes the nurses’ autonomy and the ability think critically.

Sample Question:

A patient is experiencing fever with a temperature of 38.4ºC. What priority nursing action is needed to be done?
  1. Assess the client for underlying conditions
  2. Administer Paracetamol 500mg, P.O.
  3. Give the client a Tepid Sponge Bath(TSB)
  4. Alert the attending physician of the clients condition

Performing a Tepid Sponge Bath on a client is an immediate action of nurses, to reduce a client’s elevated temperature that most often does not need a doctor’s order unless contraindicated. If the client is given a TSB and the client’s temperature does not go down, then the nurse can now administer other nursing procedures such as administration of ordered medication.

Remember to only use this test taking strategy if you DO NOT KNOW the correct answer and is UNSURE of the choices. If you know the answer and it contradicts any test taking strategy, please follow what you know.