Priority Setting and Frameworks Beginning & Advanced Test

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 working the 7 p.m. to 7 a.m. 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 hrs b. A school-aged 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 cleft palate repair with a HR of 146/min and a RR of 28/min

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

A nurse is reviewing the lab results for four clients. 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 c. Potassium 3.5 mEq/L

b. Platelets 95,000 mm^3

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

c. Hypoxic

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? a. Check on the client b. Unlock the crash cart c. Begin CPR d. Announce a code

a. Check on the client

A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's SpO2 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

d. Assist client to cough effectively

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

d. Diarrhea Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood volume. Based on this knowledge and using the ABC priority setting framework, this is the highest priority finding by the nurse.

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

d. Engage the client in physical activity

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

a. Immediate Clients assigned to the immediate triage category in a mass casualty event have life-threatening, but survivable injuries if immediate care is received. Based on the survival potential priority setting framework, the nurse should provide priority care to clients in this category. Clients assigned to the delayed triage category in a mass casualty event have significant injuries, but can wait up to 2 hr before receiving care. The nurse should not provide priority care to clients in this category. . Clients assigned to the minimal triage category in a mass casualty situation can wait several hours to days before receiving care. The nurse should not provide priority care to clients in this category. Clients assigned to the expectant triage category in a mass casualty situation are not expected to survive and are provided comfort measures only. The nurse should not provide priority care to clients in this category.

A nurse 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? a. Place the infant in a supine position when sleeping b. Place the infant on a firm mattress when sleeping c. Avoid covering the infant with loose bedding while sleeping d. Avoid leaving stuffed animals in the crib with the sleeping infant

a. Place the infant in a supine position when sleeping Evidence-based practice and current recommendations of the American Academy of Pediatrics include positioning the infant supine while sleeping. This intervention has had the greatest impact on reducing the occurrence of SIDS. Using the safety and risk reduction priority setting framework and nursing knowledge, this is the priority information to include in the discharge teaching.

A nurse has been assigned to care for four clients on a med-surg 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 RBCs for hemoglobin of 7.8 gm/dL

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

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

b. Check the heart rate and blood pressure

A nurse is assisting with the admissions 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

b. Check the leg for warmth and edema Before you can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's condition, you must first collect adequate data from the client. Based on the cause of the decreased circulation, it is possible that an anticoagulant should be administered; however, this is not the first action the nurse should take.

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 raised position d. Plan a fall prevention program for clients at risk

b. Determine the mobility status of each client

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

b. Digoxin 3.0 ng/mL

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

b. Perform fingersticks for glucose levels on clients who have diabetes mellitus

A nurse is caring for a client who is having difficultly 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

b. Place the client in the orthopneic position

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 priority concern of the nurse? a. Enhancing self-esteem b. Preventing injury c. Encouraging problem solving d. Promoting usefulness

b. Preventing injury

A 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? 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

b. Use a properly-fitted bicycle helmet

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 actions 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

c. Check pedal pulse

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 Client needs should then be addressed by following the remaining four hierarchal levels. It is important, however, to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow's hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs. Establishing a sense of achievement is associated with self-esteem, which would be a component of the fourth level of Maslow's Hierarchy of Needs. While it is important to consider this need, it is not the client's priority need at this time. Social relationships are a component of friendship, which would be included in the third level of Maslow's Hierarchy of Needs. Based on Maslow's Hierarchy of Needs, this is the client's priority need.

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

c. Maintaining a patent airway ABC airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them

A nurse is collecting data on four 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 Warmth and pain in the calf is indicative of deep-vein thrombosis, which places the client at risk for pulmonary embolism.

A nurse in a rehabilitation 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 ago and reports feeling his incision pop

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

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 hx 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

d. A client who is having a nosebleed associated with hypertension

A nurse is preparing to administer oral medications to a client who has unilateral weakness following a CVA. Which of the following 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

d. Have the client position the head with the chin down while swallowing Unless contraindicated, it is appropriate to administer medications with meals so the client experiences less gastric irritation; however, another action increases client safety and should be the nurse's priority action.

A nurse is caring for a client who has a UTI. 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 a soft wrist restraints d. Move the client to a room near the nurses' station

d. Move the client to a room near the nurses' station

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

a. Initiate a bladder training schedule

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 HR c. Maternal deep-tendon reflexes d. Maternal urinary output

a. Maternal respirations