Priority Setting Frameworks
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 elastic stockings D) Promote bed rest & extremity elevation
B) Check the leg for warmth and edema Framework: Nursing process/data collection If warmth and edema is found in the leg, this indicates that the decreased circulation could be due to a deep-vein thrombosis.
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 Framework: ABCs Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood volume.
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? A) obtain an arterial pH level B) check the HR and BP C) insert an indwelling catheter D) collect a serum BUN and creatinine
B) Check the heart rate and blood pressure Framework: least restrictive, least invasive An increase in heart rate and decrease in blood pressure are consistent with a fluid volume deficit.
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 w/ ambulation when indicated B) determine the mobility status of each patient C) Maintain the side rails of each be in the raised position D) Plan a fall prevention program for clients at risk
B) Determine the mobility status of each patient Framework: nursing process Determining the mobility status of each client will help to identify those patients who are at risk for falls.
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? A) providing pain control B) preventing hemorrhage C) maintaining a patent airway D) ensuring adequate fluid intake
C) Maintaining a patent airway Framework: ABC An airway obstruction is a potential complication for clients following head and neck surgery secondary to production of mucus and needs for suctioning.
A nurse is collecting data on four clients. Which of the following findings is the most urgent? A) bladder distension and urgency B) pedal edema C) warmth and pain in the calf D) hypoactive bowel sounds
C) Warmth and pain in the calf Framework: urgent vs. non-urgent Warmth and pain in the calf is indicative of deep-vein thrombosis, which places the client at risk for pulmonary embolism.
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? A) immediate B) delayed C) minimal D) expectant
A) Immediate Framework: survival potential priority 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 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? A) Administer medications w/ meals when possible B) Ensure client understanding of medication's effects C) Determine the client's ability to self-administer meds D) have the client position the head w/ chin down while swallowing
D) Have the client position the head with the chin down while swallowing Framework: safety and risk reduction 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.
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 Framework: Maslow's Hierarchy of needs Hypoxemia indicates reduced blood oxygen levels, which involves the physiological needs of the client and is the first level.
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 cardiopulmonary resuscitation D) announce a code
A) Check on the client Framework:nursing process/data collection 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. Leads also could fall off.
A nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be immediately reported to the provider? A) Lithium carbonate 0.8 mmol/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 Framework: unstable vs. stable This digoxin level is above the expected reference range and indicates digoxin toxicity The therapeutic range for lithium has been established at 0.6 - 1.2 mmol/L. Therapeutic serum digoxin levels range from 0.5-2 ng/mL. Conventional dosing of gentamicin: Peak: 4-10 mcg/ml. Magnesium sulfate therapeutic level of 3.5 to 7 mEq/L.
A nurse is caring for a client who is having difficulty 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 suction
B) Place the client in the orthopneic position Framework: least restrictive, least invasive Placing the client in the orthopneic position allows for maximum chest expansion, which improves respiratory effort.
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 D) Potassium 3.5 mEq/L
B) Platelets 95,000 mm3 Framework: unstable vs. stable This platelet level is below the expected reference range and indicates the client is at risk for bleeding. A normal platelet count ranges from 150,000 to 450,000 platelets per mm^3. Total cholesterol levels less than 200 mg/dL are considered desirable for adults. A reading between 200 and 239 mg/dL is considered borderline high. A normal BUN is around 7 to 20 mg/dL. The normal potassium level in the blood is 3.5-5.0 mEq/L.
A nurse in a rehabilitation facility 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) 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 had abdominal surgery 10 days ago and reports feeling his incision pop
D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop Framework: acute vs. chronic Clients often report feeling the incision pop, indicating either dehiscence or evisceration has occurred.
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 is has a history of HF B) a client who has type 1 DM C) a client who is reporting pain associated w/ osteoarthritis of the knees D) a client who is having a nosebleed associated w/ hypertension
D) A client who is having a nosebleed associated with hypertension Framework: acute vs. chronic A nose bleed, or epistaxis, is an acute condition requiring immediate intervention to prevent further blood loss. Additionally, this may indicate blood pressure above the reference range requiring further assessment/intervention.
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
A) Obtain an ECG Framework: Maslows Hierarchy of needs Obtaining an ECG will assist in determining the presence of dysrhythmias related to a serum potassium level below the expected reference range.
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? 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 Framework: safety and risk reduction This intervention has had the greatest impact on reducing the occurrence of SIDS.
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? A) establishing a sense of achievement B) contributing to society C) creating meaningful social relationships D) enhancing self- confidence
C) Creating meaningful social relationships Framework:Maslows Hierarchy of needs Social relationships are a component of friendship, which would be included in the 3rd level
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? 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 Framework: ABC Assisting the client to cough effectively opens the airway by removing secretions.
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? A) Ensure all 4 side rails are up. B) Administer a prescribed sedative. C) Place the client in soft wrist restraints D) Move the client to a room near the nurses' station
D) Move the client to room near the nurses station Framework: least restrictive, least invasive Moving the client to a room near the nurses station allows for more frequent observation and promotes client safety.
