ATI Nurse Logic: Priority Setting Frameworks

A nurse is caring for a client who has a flaccid bladder following a spinal cord injury. Which of the following actions should the nurse take first? A. Initiate a bladder training schedule B. Administer solifenacin (Vesicare) C. Insert an indwelling urinary catheter D. Perform intermittent catheterization

Initiate a bladder training schedule

A nurse is caring for a client who has a urinary tract infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first? A. Ensure all four side rails are up B. Administer a prescribed sedative C. Place the client in soft wrist restraints D. Move the client to a room near the nurse's stations

Move the client to a room near the nurse's station

A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first? A. Place O2 at 2 L per nasal canula on the client B. Place the client in the orthopneic position C. Perform chest percussion D. Perform nasotracheal suctioning

Place the client in the orthopneic position

A nurse is reinforcing discharge teaching to anew mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions? A. Place the infant in a supine position when sleeping B. Place the infant on a firm mattress when sleping C. Avoid covering the infant with loose bedding while sleeping D. Avoid leaving stuffed animals in the crib with the sleeping infant

Place the infant in a supine position when sleeping

A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. Which of the following client data is most important for the nurse to monitor? A. maternal respirations B. fetal heart rate C. maternal deep-tendon reflexes D. maternal urinary output

maternal respirations

A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention? A. A client who has cystic fibrosis and has a paroxysmal cough B. A client who is prescribed cromolyn sodium (Crolom) and has a peak expiratory flow rate of 79% C. A client who has celiac disease and abdominal distension D. A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomitting

A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomitting

A nurse is caring for a client who is 48 hr postoperative following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent? A. Absent bowl sounds B. Serum BUN level 22 mg/dL C. Absent dorsalis pedis pulses C. Serum creatinine level of 1.3 mg/dL

Absent dorsalis pedis pulses

A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. For which of the following complications is it most important for the nurse to monitor? A. Diplopia B. Loss of bladder control C. Paresthesias D. Decreased respiratory effort

Decreased respiratory effort

A nurse is preparing to administer oral medications to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse? A. Administer medications with meals when possible B. Ensure client understanding of medication's effects C. Determine the client's ability to self-administer medications D. Have the client position the head with the chin down while swallowing

Have the client position the head with the chin down while swallowing

A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first? A. Homelessness B. Lack of family support C. Hypoxic D. Under nourished

Hypoxic

A nurse is reviewing the lab results for four clients. The client with which of the following values reqiures immediate intervention? A. Cholesterol 220 mg/dL B. Platelets 95,000 mm3 C. BUN 20mg/dL D. Potassium 3.5 mEq/L

Platelets 95,000 mm3

A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern? A. Promoting oxygenation B. Management of pain C. Maintaining hydration D. Preventing infection

Promoting oxygenation

A nurse is caring for a client who is postoperative and whose airway is patent and respirations are 20 breaths per minute. Which of the following assessments should the nurse conduct in relation to the client's circulatory status? Select all that apply. A. Blood pressure B. Urinary output C. Amount of intravenous fluids received D. Skin turgor E. Pulse

A B D E

Which of the following can be used to help to determine the priority risk of a client who has multiple risks? Select all that apply A. Maslow's Hierarchy of Needs B. Client's perception of priority risk C. Determining the complication that poses the highest risk D. Assessment of airway, breathing, and circulation needs E. Number of licensed and unlicensed nurses on RN's team

A C D

Interventions that are least invasive are desirable because of which of the following? Select all that apply A. The number of organisms introduced into the body is reduced B. The risk of developing antibiotic resistant microbes is increased C. The incidence of hospital acquired infections will be increased D. The client's immune system may be compromised due to the stress of the illness E. The use of equipment that penetrates the body's natural barriers increases the client's risk for infection

A D E

A nurse has been assigned to care for four clients on a medical-surgical floor. Which of the following clients should the nurse evaluate first? A. A client 48 hr following abdominal surgery with redness and swelling at the edges of the incision B. A client following knee replacement surgery complaining of pain and warmth in the calf C. A client admitted with cholecystitis who reports frequent nausea and vomiting D. A client admitted with a GI bleed receiving packed RBC's for hemoglobin of 7.8 gm/dL

A client following knee replacement surgery complaining of pain and warmth in the calf

A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first? A. A client who has peripheral vascular disease and reports numbness in the toes B. A client who has depression and is easily distracted C. A client who has Alzheimer's disease and is unable to complete activities of daily living D. A client who had abdominal surgery 10 days ago and reports feeling his incision pop

A client who had abdominal surgery 10 days ago and reports feeling his incision pop

A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first? A. A client who has COPD with an oxygen saturation of 90% B. A client who has diabetes mellitus with a HbA1C of 9% C. A client who has heart failure with 2+ pitting edema of the lower extremities D. A client who has a fever of 38.4C (101.2F) with tenderness in the right lower quadrant

A client who has a fever of 38.4C (101.2F) with tenderness in the right lower quadrant

A nurse in a provider's office is collecting data on a group of clients who are pregnant. Which of the following clients should be the nurse's priority concern? A. A client who is 26 weeks of gestation reporting leukorrhea B. A client who is 10 weeks of gestation and reporting urinary frequency C. A client who is 37 weeks of gestation and reporting perineal discomfort D. A client who is 34 weeks of gestation and reporting abdominal tenderness

A client who is 34 weeks of gestation and reporting abdominal tenderness

A nurse in a provider's office has collected data on four clients. Which of the following clients should be the nurse's priority concern? A. A client who has a history of heart failure B. A client who has type 1 diabetes mellitus C. A client who is reporting pain associated with osteoarthritis of the knees D. A client who is having a nosebleed associated with hypertension

A client who is having a nosebleed associated with hypertension

An unstable client may be defined as one who fits which of the following descriptions? A. A client whose newly placed tracheostomy is producing a large amount of secretions B. A client's whose blood pressure is lower after surgery than it was upon admission C. A client whose morning assessment reveals the presence of a wound infection D. A client who is confused and continues to get out of bed without assistance

A client whose newly placed tracheostomy is producing a large amount of secretions

A nurse working the 7 pm to 7 am shift on the pediatric unit has received report on four postoperative clients. Which of the following requires immediate intervention? A. An adolescent who is postoperative following an appendectomy and has refused to ambulate for the past 8 hr B. A school-age child who is postoperative following a herniorrhaphy with an infiltrated peripheral IV that has been clamped C. A preschooler who is postoperative following a tonsillectomy and is experiencing frequent swallowing D. An infant who is postoperative following a clef palate repair with a heart rate of 146/min and a respiratory rate of 28/min

A preschooler who is postoperative following a tonsillectomy and is experiencing frequent swallowing

A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first? A. Initiate oxygen therapy B. Encourage an increase in oral fluids C. Provide room humidification D. Assist client to cough effectively

Assist client to cough effectively

A nurse is working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first? A. Check on the client B. Unlock the crash cart C. Begin cardiopulmonary resuscitation D. Announce a code

Check on the patient

A nurse is caring for a client who has a compound fracture of the tibia and fibula and is in skin traction. The client reports pain of 6 on a scale of 0 to 10 under the traction bandage. Which of the following action should the nurse take first? A. Administer an analgesic B. Assist the client to shift positions C. Check pedal pulse D. Distract the client with music therapy

Check pedal pulse

A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for a fluid volume deficit? A. Obtain an arterial pH level B. Check the heart rate and blood pressure C. Insert an indwelling catheter D. Collect a serum BUN and creatinine

Check the heart rate and blood pressure

A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take? A. Administer an anticoagulant B. Check the leg for warmth and edema C. Apply elastic stockings D. Promote bed rest and extremity elevation

Check the leg for warmth and edema

Which of the following statements explain why the needs of a client which a chronic illness are usually of lower priority than clients with an acute need? A. Chronically ill clients are usually less ill than clients with acute illnesses B. Chronically ill clients have had the opportunity to physically adjust to their illnesses C. Acutely ill clients usually have more needs in relation to safety and security D. Acutely ill clients adapt to their illness less effectively because of its temporary nature

Chronically ill clients have had the opportunity to physically adjust to their illnesses

A nurse is performing triage at a mass casualty event and is selecting a tag for a client who is severely injured and has no potential for survival. Which of the following tags should the nurse apply to the client? A. Class I B. Class II C. Class III D. Class IV

Class IV

A nurse is caring for an older adult client who recently experience the death of her partner. Which of the following is the priority need of the client? A. Establishing a sense of achievement B. Contributing to society C. Creating meaningful social relationships D. Enhancing self-confidence

Creating meaningful social relationships

A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first? A. Provide assistance with ambulation when indicated B. Determine the mobility status of each client C. Maintain the side rails of each bed in the raised position D. Plan a fall prevention program for clients at risk

Determine the mobility status of each client

A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse? A. Malaise B. Anorexia C. Headache D. Diarrhea

Diarrhea

A nurse is conducting therapeutic medication monitoring on four clients. Which of the following findings should be immediately reported to the provider? A. Lithium carbonate 0.8 mEq/L B. Digoxin 3.0 ng/mL C. Peak serum gentamicin 6 mcg/mL D. Magnesium sulfate 4 mEq/L

Digoxin 3.0 ng/mL

A nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first? A. Administer an anti-anxiety medication B. Take the client to a place of seclusion C. Obtain an order for soft wrist restraints D. Engage the client in physical activity

Engage the client in physical activity

A nurse is caring for a client who has a fractured hip and a respiratory rate of 26/min. Which of the following actions should the nurse take first? A. Evaluate level of consciousness B. Place the client on bed rest C. Encourage increased fluid intake D. Initiate continuous ECG monitoring

Evaluate level of consciousness

A nurse is caring for a client who has a radial head fracture. Which of the following should be the priority action by the nurse following application of the cast? A. Promote adequate intake of calcium B. Evaluate neurovascular status C. Elevate the extremity above the heart D. Apply ice intermittently for the first 24 hr.

Evaluate neurovascular status

A newly hired nurse is reviewing the facility's emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide priority care to clients who are in which of the following categories during a disaster? A. Immediate B. Delayed C. Minimal D. Expectant

Immediate

A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurse's priority concern? A. Facial abrasions B. Penetrating head wound C. Incomplete amputation of the foot D. Tibia fracture requiring open reduction

Incomplete amputation of the foot

A nurse is caring for a client who is in the immediate postoperative period following a tracheotomy. Which of the following is the nurse's priority action? A. Providing pain control B. Preventing hemorrhage C. Maintaining a patent airway D. Ensuring adequate fluid intake

Maintaining a patent airway

A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first? A. Obtain an ECG B. Administer oral potassium C. Encourage potassium-rich foods D. Monitor I & O

Obtain an ECG

A nurse is caring for a toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse? A. Administer nebulized epinephrine B. Ensure adequate hydration C. Obtain an oxygen saturation level D. Encourage parents to comfort the client

Obtain an oxygen saturation level

A nurse is caring for a client who was admitted to the unit 3 hr ago following a total hip arthroplasty. Which of the following findings should be nurse's priority concern? A. Urinary output of 75 mL over the past 3 hr B. 8-point elevation in the pre-surgery diastolic blood pressure C. Oxygen saturation of 90% on oxygen at 2 L per nasal cannula D. Core body temperature of 36.2C (97.2F)

Oxygen saturation of 90% on oxygen at 2 L per nasal cannula

Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first? A. Bathe a client who is scheduled for physical therapy at 9 am B. Perform fingersticks for glucose levels on clients who have diabetes mellitus C. Stock procedure rooms D. Distribute clean linens

Perform fingersticks for glucose levels on clients who have diabetes mellitus

A nurse is caring for a client who is newly diagnosed with bipolar disorder and is currently experiencing an acute manic episode. Which of the following is the primary concern of the nurse? A. Enhancing self-esteem B. Preventing injury C. Encouraging problem solving D. Promoting usefulness

Preventing injury

Which of the following priority setting frameworks is being applied by a nurse who has decided to hang a client's intravenous antibiotic within 30 minutes of the time specified instead of giving another client their PRN pain medication? A. Least invasive B. Airway, Breathing, Circulation C. Urgent vs. nonurgent D. Safety and risk reduction

Urgent vs. nonurgent

A school nurse is reinforcing teaching regarding bicycle safety to a group of school-aged children. Which of the following is the most important concept to include in the teaching? A. Place proper lights and reflectors on the bicycle B. Use a properly-fitted bicycle helmet C. Wear light-colored clothing at night D. Use hand signals when turning

Use a properly fitted bicycle helmet

A nurse is collecting data on four clients. Which of the following findings is the most urgent? A. Bladder distension and urgency B. Pedal edema C. Warmth and pain in the calf D. Hypoactive bowl sounds

Warmth and pain in the calf

A nurse is caring for a client who is confused and disoriented. The client has been getting out of the wheelchair when in her room and going into the bathroom without assistance. Which of the following interventions would be the least restriction but most effective to use with this client? A. Wrist only restraints B. Wheelchair alarm C. Mattress beside the bed D. Mild sedative

Wheelchair alarm