ATI - Priority Setting Frameworks Beginning & Advanced Test

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 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 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 followiwng clients should the nurse evaluate first?

A client who has a fever of 38.4 C 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 client who is 34 weeks 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 client who is having a nosebleed associated with hypertension

A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention?

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

A nurse working the 7pm to 7 am shift on the pediatric unit has receieved report on four postoperative clients. Which of the following requires immediate intervention?

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

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?

Absent dorsalis pedis pulses

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 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 has a compound fracture of the tibia and fibula and is in the skin traction. The client reports pain of 6 on a scale of 0 to 10 under the traction bandage. Which of the following actions should the nurse take first?

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 fluid volume deficit?

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?

Check the leg for warmth and edema

A nurses 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 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?

Decreased respiratory effort

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 patient

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

Diarrhea

A nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be immediately reported to the provider?

Digoxin 3.0ng/mL

A nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first?

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?

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?

Evaluate neurovascular status

A nurse is preparing to administer oral medication 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 nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first?

Hypoxic

A newly hired nurse is reviewing the facilities emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide power you care to clients who are in which of the following categories during a disaster?

Immediate

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?

Initiate a bladder training schedule

A nurses caring for a client who is in the immediate post operative period following a tracheotomy. Which of the following is the nurses priority action?

Maintaining a patent airway

A nurses caring for a client who has a urinary track 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 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 toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse

Obtain an oxygen saturation level

A nurse is caring for a client who was admitted to the unit 3 hour ago following a total hip arthroplasty. Which of the following findings should be nurse's priority concern?

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. Which of the following tasks should the nurse have the AP perform first?

Perform fingersticks for glucose levels on client who have diabetes mellitus

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 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 mm3

A nurse is caring for a client who is newly diagnosed with bipolar disorder and is currently experiencing an acute manic opisode. Which of the following is the priority concern of the nurse?

Prevent injury

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?

Promoting oxygenation

A school nurse is reinforcing teaching regarding bicycle safety to a group of school-age children. Which of the following is the most important concept to include in the teaching?

Use a properly-fitted bicycle helmet

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

Warmth and pain in the calf

A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should the nurse's priority concern?

incomplete amputation of the foot

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?

maternal respirations