Beginner Priority Setting Frameworks

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?

Have the client position the head with the chin down while swallowing. Clients are at risk for aspiration following a CVA, and having the client position the head with the chin down while swallowing reduces this risk. Based on the safety and risk reduction priority setting framework, this should be the nurse's priority action. Preventing aspiration is further supported as the priority by the ABC priority setting framework.

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?

Immediate The highest priority is assigned to the client with injuries that are severe, but has the potential to survive with treatment. Clients assigned to the immediate triage category in a mass casualty event have life-threatening, but survivable injuries if immediate care is received.

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 patent airway. Using the ABC priority setting framework, maintaining a patent airway is the nurse's priority action for a client who is in the immediate postoperative period following a tracheotomy. An airway obstruction is a potential complication for clients following head and neck surgery secondary to production of mucus and need for suctioning.

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. Placing the client in the orthopneic position allows for maximum chest expansion, which improves respiratory effort. Based on the least restrictive, least invasive priority setting framework, this should be the first action the nurse takes.

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 nose bleed, or epistaxis, is an acute condition requiring immediate intervention to prevent further blood loss. Additionally, this finding can be associated with a blood pressure that is above the expected reference range, indicating the need for further intervention

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 9 0 % on room air. Which of the following actions should the nurse take first?

Assist client to cough effectively. Start with the intervention that requires the least manipulation of client. A clear airway is necessary for oxygen exchange to occur.

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

Hypoxic Hypoxemia indicates reduced blood oxygen levels, which involves the physiological needs of the client and is the first level of Maslow's Hierarchy of Needs. Because oxygen is considered the most basic physiological need, this is the need the nurse should address first.

A nurse is caring for a client who has a urinary tract infection. The client is disoriented and found wandering on another unit. Which action should the nurse take first?

Moving the client to a room near the nurses' station allows for more frequent observation and promotes client safety. Using the least restrictive, least invasive priority setting framework, this action is less restrictive than the other actions and should be the nurse's first action.

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?

Creating meaningful social relationships

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

Digoxin 3.0 ng/mL

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. Obtaining an ECG will assist in determining the presence of dysrhythmias related to a serum potassium level below the expected reference range. According to Maslow's Hierarchy of Needs priority setting framework, physiological needs, such as adequate cardiac functioning, receive highest priority

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 Answering this item requires application of the acute versus chronic priority setting framework. Using this framework, acute needs are typically the priority need because they pose more of a threat to the client. Because chronic needs usually develop over a period of time, the client has more of an opportunity to adapt to the alteration in health. It is also important to attend to alterations when they are in the acute phase so they don't escalate into a life-threatening event or evolve into a chronic alteration in health.

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 client. Determining the mobility status of each client will help to identify those patients who are at risk for falls. This knowledge will ensure the implementation of education and prevention efforts specific to the needs of each client.

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. If the client is able to be aroused or a pulse is palpated, then the client is not in cardiac arrest, and there is a problem with the monitoring equipment. It is common for leads to become loose or fall off clients when they move around, resulting in the monitor detecting an absence of cardiac function. Therefore, checking on the client is the first action the nurse should take.

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 HR and BP. An increase in heart rate and decrease in blood pressure are consistent with a fluid volume deficit. Using the least restrictive, least invasive priority setting framework, this action is less invasive than the other actions and should be the nurse's first action.

A nurse is assisting with the admission of a client who has decreased circulation in the left leg. What should be the nurses first action?

Check the leg for warmth and edema. 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.

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

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

Platelets 95,000 mm3 This platelet level is below the expected reference range and indicates the client is at risk for bleeding. Based on the stable versus unstable priority setting framework and nursing knowledge, the client with this laboratory value requires immediate intervention.

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

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. Using the urgent versus non-urgent priority setting framework and nursing knowledge, this is the finding that represents the most urgent need. This option is further supported by the ABC priority setting framework.