Priority Setting Frameworks (Beginner Test)

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 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.

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

Digoxin 3.0 ng/mL Rationale: 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 the following findings is the most urgent?

Warmth and pain in the calf Rationale: Using the urgent versus non-urgent priority setting framework, the most urgent finding is warmth and pain in the calf of a client. 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.

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 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 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

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 Rationale: 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 normal platelet count ranges from 150,000 to 450,000 mm3

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

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 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 heart rate and blood pressure.

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 Rationale: Wound dehiscence or evisceration most commonly occurs 3 to 11 days following surgery and can be caused by not splinting the surgical site when moving, forceful coughing, vomiting, or straining. Clients often report feeling the incision "pop," indicating either dehiscence or evisceration has occurred. Based on the acute versus chronic priority setting framework, the nurse should evaluate this client first.

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 Rationale: 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. Based on the acute versus chronic priority setting framework, this client should be the nurse's priority.

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

​Hypoxic

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

Diarrhea Rationale: 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. Using the ABC priority setting framework, maintaining circulation is the nurse's priority concern. 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 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.

A nurse is caring for a client who has a urinary tract 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 a 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? Options: Obtain an ECG. Administer oral potassium. Encourage potassium-rich foods Monitor I & O.

Obtain an ECG. Rationale: 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 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.