Priority Setting Frameworks - Beginner
A nurse 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?
Check on the client.
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?
Check the heart rate and blood pressure.
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?
Determine the mobility status of each client.
A nurse is collecting data on four clients. Which of following is the highest priority finding by the nurse?
Diarrhea.
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?
Have the client position the head with the chin down while swallowing.
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?
Immediate.
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?
Maintaining a patent airway.
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?
Move the client to a room near the nurses' station.
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?
Obtain an ECG.
A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?
Place the client in the orthopneic position.
A nurse is collecting data on four clients. Which of the following findings is the most urgent?
Warmth and pain 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 client who had abdominal surgery 10 days ago and reports feeling his incision pop.
A nurse is caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client?
Creating meaningful social relationships.
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?
Assist client to cough effectively.
A nurse is conducting therapeutic medication monitoring on four clients. Which of the following findings should be immediately reported to the provider?
Digoxin 3.0 ng/mL.
A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions?
Place the infant in a supine position when sleeping.
A nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention?
Platelets 95,000 mm^3.
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 client who is having a nosebleed associated with hypertension.
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?
Check the leg for warmth and edema.
A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first?
Hypoxic.