NCLEX Priority and Safety Mnemonics
On this page
Use a mnemonic as a tiebreaker
Mnemonics are compression, not understanding. They earn their keep in the last twenty seconds of an item where two options both look defensible and you need a rule to break the tie. They cost you marks when you reach for them first and stop reading the stem.
Read the body text under each one. That is where the rule lives; the acronym is just the handle.
ABC Priority
Airway beats everything
When two clients both look unstable, the one whose airway is threatened is always seen first. A patent airway is the only thing that makes breathing and circulation possible.
- Stridor, drooling, gurgling or a swollen tongue outrank chest pain
- A silent chest in asthma is worse than loud wheezing, not better
- Airway compromise from anaphylaxis or burns to the face is time-critical
When ABC does not settle it, use Maslow
If every option is physiological, drop to safety, then psychosocial. A client at risk of falling outranks a client who is anxious about discharge.
- Physical need beats emotional need unless the client is actively suicidal
- Actual problems outrank potential problems
- Unstable outranks stable, even if the stable client is more distressed
Acute beats chronic, unexpected beats expected
A finding that fits the client’s diagnosis can usually wait. A finding that does not fit is the emergency.
- Expected: mild pain after surgery. Unexpected: sudden severe abdominal pain with rigidity
- Expected: crackles in chronic heart failure. Unexpected: new crackles after a transfusion
- Expected: dark urine in dehydration. Unexpected: bright red bleeding post-op
Assess before you act
If one option gathers data and another performs an action, choose the assessment unless the client is in immediate danger.
- Exception: airway obstruction, active haemorrhage, cardiac arrest – act first
- Exception: a monitor alarm always gets a look at the client, not the machine
- Auscultating, palpating and asking are all assessments
Safety First
Never delegate what you can EAT
Evaluation, assessment, teaching, and anything requiring nursing judgement stay with the registered nurse. Unlicensed staff get stable, predictable, routine tasks.
- Assistive personnel: bathing, feeding a stable client, vital signs on a stable client, ambulating, intake and output
- Licensed practical nurse: stable clients, routine medications by scope, dressing changes, reinforcing teaching
- Registered nurse: first assessment, unstable clients, blood products, IV push in most settings, care planning
Two identifiers, every time
Two client identifiers are required before any medication, procedure, specimen collection or blood product.
- Room number and bed number are never acceptable identifiers
- Blood products need two licensed staff verifying at the bedside
- Check the identifier against the record, not against what the client answers alone
Restraints are the last resort
Try every alternative first, get an order that is time-limited and never PRN, and document assessment on a strict schedule.
- Attempt distraction, family presence, bed alarms and reorientation before restraint
- Quick-release knot tied to the movable bed frame, never the side rail
- Check circulation, offer fluids, toileting and range of motion at least every two hours
Fire response order
Rescue anyone in immediate danger, Activate the alarm, Confine the fire by closing doors, then Extinguish or Evacuate.
- PASS the extinguisher: Pull the pin, Aim at the base, Squeeze, Sweep
- Move ambulatory clients first, then wheelchair, then bedbound
- Turn off oxygen sources in the affected area
Emergency Priorities
Triage tags in a mass casualty
Red means life-threatening but survivable with immediate care. Green are the walking wounded. Black are expectant.
- Red: airway compromise, uncontrolled bleeding, tension pneumothorax, shock
- Yellow: open fracture, large burn without airway involvement, stable abdominal injury
- Green: sprains, minor lacerations, anxiety without injury
Anaphylaxis sequence
Intramuscular epinephrine into the outer thigh comes before antihistamines, steroids or anything else.
- Stop the trigger, call for help, give epinephrine
- Maintain the airway and give high-flow oxygen
- Antihistamines and corticosteroids are adjuncts, not the treatment
Increased intracranial pressure
Widening pulse pressure with bradycardia is a late and ominous sign.
- Head of bed 30 degrees, head midline, no neck flexion
- Avoid coughing, straining, suctioning longer than 10 seconds and clustered care
- A change in level of consciousness is the earliest sign
Autonomic dysreflexia
Seen in spinal cord injury at or above T6: pounding headache, severe hypertension, flushing above the lesion and sweating.
- Raise the head of the bed immediately to lower blood pressure
- Look for a blocked catheter, full bladder, impaction or tight clothing
- Do not leave the client; it can cause stroke within minutes
Transfusion reaction response
Stop the blood, keep the line open with normal saline through new tubing, stay with the client, then notify.
- Fever with chills in the first 15 minutes suggests a haemolytic reaction
- Return the bag and tubing to the laboratory
- Most reactions appear in the first 15 minutes, which is why you stay at the bedside
Isolation Precautions
Airborne: My Chicken Has TB
Negative-pressure room and an N95 respirator. Chickenpox and disseminated zoster also need contact precautions.
- Private negative-pressure room with the door closed
- N95 or higher for every person entering
- Surgical mask on the client for essential transport
Droplet: SPIDERMAN
Private room preferred, surgical mask within about two metres, and a mask on the client during transport.
- Droplets fall quickly, so no special air handling is needed
- Meningococcal disease also needs prophylaxis for close contacts
- Pertussis stays on precautions for five days of effective therapy
Contact: MRS WEE
Gown and gloves on entry, dedicated equipment, and a private room where possible.
- C. difficile needs soap and water, not alcohol rub, and bleach-based cleaning
- Scabies, impetigo, herpes simplex and pediculosis are all contact
- Remove personal protective equipment before leaving the room
Protective isolation reverses the flow
Used for severe neutropenia, transplant and burns. The precautions protect the client from visitors and the environment.
- Positive-pressure room with HEPA filtration
- No fresh flowers, standing water, raw produce or unpasteurised food
- Anyone with a cold stays out
PPE order
Gloves go on last and come off first because they are the dirtiest item. The mask comes off last, outside the room where possible.
- Remove gloves without touching the outer surface
- Perform hand hygiene between steps if contamination occurs
- The mask is untied from the bottom tie first
More NCLEX practice and review
Everything on this site tagged NCLEX lives in the NCLEX category.