ATI priority setting framework review test

A nurse in the providers office has collected data on for clients which of the following clients should be the nurses priority concern?

a) A client who has a history of heart failure b) A client with type one 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 d) A client who is having a nosebleed associated with hypertension

A nurse in a rehabilitation facility has received your part on for 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 is easily distracted c) A client who has Alzheimer's disease and is unable to complete ADLs d) A client who has abdominal surgery 10 days ago and reports feeling his incision pop d) A client who has abdominal surgery 10 days ago and reports feeling his incision pop

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 elastics stalking d) promote bedrest and extremity elevation b) Check the leg for warmth and edema ; prioritize data collection in order to implement plan; if warmth and edema is found in the leg this indicates the decreased circulation could be due to deep vein thrombosis

A nurse in a long-term care facility is assisting with admissions of several clients to prevent falls in hospitalize 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 race position d) plan a fall prevention program for clients at risk b) Determine the mobility status of each client

A nurse is caring for a client who is in the immediate postoperative. Following a tracheostomy. Which of the following is the nurses priority action?

a) Provide pain control b) Preventing hemorrhage c) Maintain patient airway d) ensure adequate fluid intake c) Maintain patient airway

A nurse is reviewing the lab results for for client the client with which of the following values requires immediate intervention?

a) cholesterol 220 mg/dL b) platelets 95,000 mm^3 c) BUN 20 mg/dL d) potassium 3.5 mEq/L b) platelets 95,000 mm^3 ; immediate intervention because at risk for bleeding - cholesterol is above expected range and should be provided information about healthy diet and exercise

A nurse is conducting therapeutic medication monitoring on for 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 b) digoxin 3.0 ng/mL ; above expected range= digoxin toxicity

A nurse is collecting data on for clients which of the following is the highest priority finding by the nurse?

a) malaise b) anorexia c) headache d) diarrhea d) diarrhea ; ABC's diarrhea can decrease in circulating blood volume by deplete body of fluids

A nurse is caring for a client who has 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 a) obtain an ECG ; normal serum potassium levels: 3.6 to 5.2 mEq/L

A nurse is preparing to administer oral medications to a client who has unilateral weakness following a cerebral vascular accident which of the following should be the priority action of the nurse?

a) Administer medication's with meals when possible b) Ensuring clear understanding of medication effects c) Determine the clients ability to self administer medication d) have the client position the head of the chin down while swallowing d) have the client position the head of the chin down while swallowing

A nurse is collecting data on for clients which of the following findings is the most urgent?

a) Bladder distention and urgency b) Pedal edema c) Warmth and pain in the calf d) hypoactive bowel sounds c) Warmth and pain in the calf ; can indicate deep venous thrombosis which place the client at risk for pulmonary embolism

A nurse working on the cardiac unit here's an alarm and finds one of the heart monitor screens at the nurses 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 cardio pulmonary resuscitation d) announce a code a) Check on the client

A nurse is caring for a client who has a UTI then client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first?

a) Ensure all for side rails are up b) administer a prescribed sedative c) Please the client in softest restaurants d) move the clients room near the nurses station d) move the clients room near the nurses station

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?

a) Establishing a sense of achievement b) Contributing to society c) Creating meaningful social relationships d) enhancing self-confidence c) Creating meaningful social relationships ; Maslow's hierarchy of needs physiological needs, safety needs, love and belonging, esteem, self actualization

A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first?

a) Homelessness b) Like a family support c) Hypoxic d) Under nourished c) Hypoxic; hypoxemia indicates reduce blood oxygen levels and involves physiological needs; prioritize Maslow's hierarchy of needs because oxygen is considered basic and also ABC priority

A newly hired nurse is reviewing the facilities 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 a) Immediate ; patient in immediate triad category have life-threatening but survivable injuries if immediate care is received -delayed triage; Patient has significant injuries but can wait up to two hours before receiving care -minimal triage; Patient can wait several hours to days before receiving care -expectant triage; patient not expected to survive and I provided comfort measures only

A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions the 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 affectively d) assist client to cough affectively ; priority to open the airway by removing secretion

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 and indwelling catheter d) select a serum BUN and creatine b) Check the heart rate and blood pressure ; increase heart rate and decreased blood pressure are consistent with fluid volume deficit; use least restrictive lease invasive priority

A nurse is caring for a client who has difficulty breathing. Which of the following actions should the nurse take first?

a) Place O2 at 2 L per nasal canal on the client b) Place the client in the orthopedic position c) Perform chest percussions d) perform nasal tracheal suctioning b) Place the client in the orthopedic position; 1st: least invasive

A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome. 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 was sleeping c) Avoid covering the infant with loose bedding was sleeping d) avoid leaving stuffed animals in the crib with the sleeping infant a) Place the infant in a supine position when sleeping