Editing Nursing Skills and Procedures (section)

== Prioritization Framework for Skill-Based Items ==

When an exam item asks what the nurse does first, apply this order:
# Airway, breathing, circulation, then disability and level of consciousness.
# Acute and unstable before chronic and stable, actual problems before potential ones.
# Assess before intervening, unless the situation is a known emergency with a standing first action, such as stopping a transfusion or clamping a line for suspected air embolism.
# Protect the patient from immediate harm before notifying anyone. Notification is rarely the very first action if the nurse can do something for the patient now, but it is the correct action when the required intervention exceeds the nurse's scope or requires an order.
# For practical and vocational nurse items, ask whether the finding falls outside the established plan of care or reflects a change in status. If it does, the answer is to notify the registered nurse or provider.