ATI Nurse Logic 2.0: Priority Setting Frameworks

A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen sat lvl is 90% on room air. Which of the following actions should the nurse take first?

Assist client to cough effectively

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 hear rate and BP

A nurse in a long-term are facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following should the nurse take first?

Determine the mobility status of each client

A nurse is collecting data on four clients. Which of the following is the highest priority finding bu the nurse?

Diarrhea

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 patient airway

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 reviewing the lab results for 4 clients. The client with which of the following values requires immediate intervention?

Platelets 95,000mm3

A nurse is collecting data on four clients. Which of the following findings is the most urgent?

Warmth and pain in the calf