priority setting ATI

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?Administer an anticoagulant. Check the leg for warmth and edema. Apply elastic stockings. Promote bed rest and extremity elevation.

B

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? Initiate oxygen therapy. Encourage an increase in oral fluids Provide room humidification. Assist client to cough effectively.

D. nswering this item requires application of the ABC priority setting framework, which emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority setting framework, airway is the highest priority because the airway must be open and clear 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. Initiating oxygen therapy will improve the exchange of oxygen as long as the airway is clear; however, there is another action that provides more immediate results and should be taken first.

A nurse is conducting therapeutic medication monitoring on four clients. Which of the following findings should be immediately reported to the provider? Options: Magnesium sulfate 4 mEq/L Peak serum gentamicin 6 mcg/mL Lithium carbonate 0.8 mEq/L Digoxin 3.0 ng/mL

D. Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients get priority because of needs that threaten their survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed first. Clients whose vital signs or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed to determine which option poses the greatest risk to the client. This digoxin level is above the expected reference range and indicates digoxin toxicity. Based on the unstable versus stable priority setting framework and nursing knowledge, this lab value is the priority and should be immediately reported to the provider.

A nurse is collecting data on four clients. Which of following is the highest priority finding by the nurse?Malaise Anorexia Headache 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 in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first? A client who has peripheral vascular disease and reports numbness in the toes A client who has depression and is easily distracted A client who has Alzheimer's disease and is unable to complete activities of daily living A client who had abdominal surgery 10 days ago and reports feeling his incision pop

d

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?Administer medications with meals when possible. Ensure client understanding of medication's effects. Determine the client's ability to self-administer medications. Have the client position the head with the chin down while swallowing.

d Answering this item requires application of the nursing process priority setting framework. The nursing process is a tool that can be used to plan client care and prioritize nursing actions. Each step of the nursing process is based on the previous step, beginning with assessment or data collection. 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. Using the nursing process, assessment or data collection should be the first action taken by the nurse so a plan of care can be developed. If warmth and edema is found in the leg, this indicates that the decreased circulation could be due to a deep-vein thrombosis. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.