ATI Nurse Logic 2.0 ~ Priority Setting Frameworks (Advanced Test)

A nurse is caring for a client who has a fractured hip and a respiratory rate of 26 breaths/minute. Which of the following actions should the nurse take first? A. Evaluate level of consciousness. B. Place the client on bed rest. C. Encourage increased fluid intake. D. Initiate continuous ECG monitoring.

A. Evaluate level of consciousness. Rationale: A. 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 so a plan of care can be developed. Clients who have a fractured hip are at risk for fat embolism syndrome because of the release of fat globules from the yellow bone marrow. These globules enter the blood stream where they can travel and occlude small vessels and impair perfusion to vital organs, including the lungs. A change in the level of consciousness is the earliest manifestation of fat embolism syndrome. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care. This option is further supported by the ABC priority setting framework. B. 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 so a plan of care can be developed. Although placing the client on bed rest is an important action by the nurse, it is not the first action the nurse should take. C. 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 so a plan of care can be developed. Although encouraging increased fluid intake is an important action by the nurse, it is not the first action the nurse should take. 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 so a plan of care can be developed. Although initiating continuous ECG monitoring is an important action by the nurse, it is not the first action the nurse should take.

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.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. Rationale: A. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Interventions that are not invasive to the client should be taken before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of hospital-acquired infections. Bladder retraining is a restorative care method used with clients who have urinary incontinence. Based on the least restrictive, least invasive priority setting framework, this is the first action the nurse should take. B. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Interventions that are not invasive to the client should be taken before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of hospital-acquired infections. Solifenacin can be prescribed for the management of urinary incontinence; however, there is another action that is less invasive and should be the nurse's first action. C. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Interventions that are not invasive to the client should be taken before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of hospital-acquired infections. An Indwelling urinary catheter might be required to manage urinary incontinence; however, there is another action that is less invasive and should be the nurse's first action. D. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Interventions that are not invasive to the client should be taken before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of hospital-acquired infections. Intermittent catheterization can be prescribed to manage urinary incontinence; however, there is a less invasive action the nurse should take first.

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 heart rate C. Maternal deep-tendon reflexes D. Maternal urinary output

A. Maternal respirations Rationale: A. Answering 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 and the fetus 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 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. Using the ABC priority setting framework, maintaining a patent airway and ensuring adequate respiratory effort are priority concerns of the nurse caring for a client who is in preterm labor and is receiving magnesium sulfate. Excessive levels of magnesium can suppress neuromuscular transmission, placing the client at risk for respiratory depression. Based on this knowledge and using the ABC priority setting framework, it is most important for the nurse to monitor maternal respirations. B. Answering 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 and the fetus 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 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. Fetal heart rate should be monitored before and during magnesium therapy; however, this is not the most important data for the nurse to monitor. C. Answering 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 and the fetus 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 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. Deep-tendon reflexes should be evaluated during magnesium therapy. Absent deep-tendon reflexes are associated with magnesium toxicity; however, this is not the most important data for the nurse to monitor. D. Answering 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 and the fetus 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 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. Urinary output should be evaluated during magnesium therapy. Urine output less than 25 to 30 mL/hr or more than 100 mL/hr is associated with magnesium toxicity; however, this is not the most important data for the nurse to monitor.

A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern? A. Promoting oxygenation B. Management of pain C. Maintaining hydration D. Preventing infection

A. Promoting oxygenation Rationale: A. Answering 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 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. Using the ABC priority setting framework, maintaining a patent airway and ensuring adequate respiratory effort are the priority concerns of the nurse caring for a client who has been admitted in a vaso-occlusive crisis. Short-term oxygen therapy is used to prevent additional sickling and hypoxia. Massive systemic sickling has been linked to severe hypoxia and can be fatal. Rest should also be encouraged to decrease expenditure of energy and oxygen. Based on this knowledge and using the ABC priority setting framework, promoting oxygenation is the nurse's priority concern. B. Answering 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 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. Analgesics should be administered to the client to manage pain during a vaso-occlusive crisis; however, this is not the nurse's priority concern. C. Answering 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 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. Hydration should be maintained through oral and IV therapy for a client in vaso-occlusive crisis; however, this is not the nurse's priority concern. D. Answering 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 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. Preventing infection is important because of the client's increased susceptibility, which results from functional asplenia; however, this is not the nurse's priority concern.

A nurse is caring for a client who has a radial head fracture. Which of the following should be the priority action by the nurse following application of the cast? A. Promote adequate intake of calcium. B. Evaluate neurovascular status. C. Elevate the extremity above the heart. D. Apply ice intermittently for the first 24 hr.

B. Evaluate neurovascular status. Rationale: A. 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. Although adequate intake of calcium enhances bone healing and repair, this is not the priority action of the nurse. B. 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. Neurovascular compromise is a manifestation of compartment syndrome and must be detected in the early stages to avoid permanent damage. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care. This action can be further supported as the priority action using the ABC priority setting framework. C. 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. Although elevating the extremity above the heart can assist in reducing the swelling, this is not the priority action of the nurse. 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. Although applying ice intermittently for the first 24 hr can assist in reducing the swelling, this is not the priority action of the nurse.

Following morning report, a nurse assigns completion of several tasks to an assistive personnel. Which of the following tasks should the nurse have the AP perform first? A. Bathe a client who is scheduled for 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. Rationale: A. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It might be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Bathing a client who is scheduled for physical therapy at 9 a.m. is an important task to complete; however, there is another task that could impact the physiological safety of clients that should be performed first. B. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It might be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Performing fingersticks for glucose levels on clients who have diabetes mellitus is important in order to ensure physiological safety of the clients. Using the safety and risk reduction priority setting framework and nursing knowledge, the greatest risk to the client is hyperglycemia or hypoglycemia because of inadequate or inappropriate amounts of insulin being administered. To attain accurate readings, these levels should be attained prior to eating; therefore, this is the task the nurse should have the AP perform first. C. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It might be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Stocking procedure rooms is an important task to complete; however, there is another task that could impact the physiological safety of clients that should be performed first. D. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It might be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Distributing clean linens is an important task to complete; however, there is another task that could impact the physiological safety of clients that should be performed first.

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 Rationale: A. Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. 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 needs associated with self-esteem and usefulness. While enhancing self-esteem is an important action of the nurse, there is another concern that should be the nurse's priority. B. Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. 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 second level of Maslow's Hierarchy of Needs includes needs associated with safety and security; therefore, preventing injury is the priority action of the nurse. C. Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. 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 fifth level of Maslow's Hierarchy of Needs includes needs associated with problem solving. While encouraging problem solving is an important action of the nurse, there is another concern that should be the nurse's priority. D. Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs priority setting framework, physiological needs take precedence and should be reviewed first. Client needs should then be addressed by following the remaining four hierarchial 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 needs associated with self-esteem and usefulness. While promoting usefulness is an important action of the nurse, there is another concern that should be the nurse's priority.

A school 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. Rationale: A. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It can be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Placing proper lights and reflectors on the bicycle are important injury prevention measures; however, there is another concept that is more important to include in the teaching. B. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It can be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. A properly-fitted bicycle helmet should always be worn to prevent head injuries. Using the safety and risk reduction priority setting framework and nursing knowledge, the greatest risk to the client is blunt trauma to the head. Because adequate brainstem functioning is required to support breathing and circulation, this option is further supported by the ABC priority setting framework. C. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It can be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Wearing light-colored clothing at night is an important injury prevention measure; however, there is another concept that is more important to include in the teaching. D. Answering this item requires application of the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. It can be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Using hand signals when turning is an important injury prevention measure; however, there is another concept that is more important to include in the teaching.

A nurse has been assigned to care for four clients on a medical-surgical 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 Rationale: A. Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients are the priority because of needs that threaten the client's 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 describes the most unstable client. Redness and swelling at the edges of the incision are expected clinical findings 48 hr after abdominal surgery. While the client should continue to be monitored due to the risk for infection, there is another client that the nurse should evaluate first. B. Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients are the priority because of needs that threaten the client's 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 describes the most unstable client. Thromboembolism is a potentially serious complication after joint surgeries, particularly those involving the lower extremities. Pain, warmth, and redness are all potential clinical manifestations of a thromboembolism, which can lead to the development of a pulmonary embolism. Based on the unstable versus stable priority setting framework and nursing knowledge, this is the client the nurse should evaluate first. C. Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients are the priority because of needs that threaten the client's 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 describes the most unstable client. Nausea and vomiting are common clinical findings associated with cholecystitis. While the client should be further evaluated, there is another client that the nurse should evaluate first. D. Answering this item requires application of the unstable versus stable priority setting framework. Using this framework, unstable clients are the priority because of needs that threaten the client's 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 describes the most unstable client. This hemoglobin level is below the expected reference range; however, the client's problem is being addressed by receiving a transfusion. While the client should continue to be closely monitored, there is another client that the nurse should evaluate first.

A nurse working the 7 p.m. to 7 a.m. shift on a 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 hr B. A school-age 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 heart rate of 146/min and a respiratory rate of 28/min

C. A preschooler who is postoperative following a tonsillectomy and is experiencing frequent swallowing Rationale: A. 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 the client's 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 describes the most unstable client. An adolescent who refuses to ambulate following abdominal surgery needs additional education and encouragement; however, there is another client who is unstable and requires immediate intervention. B. 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 the client's 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 describes the most unstable client. An infiltrated peripheral IV needs to be discontinued and another IV started; however, because the IV tubing has been clamped, stopping the infusion of fluids, there is another client who is unstable and requires immediate intervention. C. 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 the client's 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 describes the most unstable client. A preschooler who is experiencing frequent swallowing following a tonsillectomy could be bleeding, placing the client at risk for hemorrhage. Bleeding from the surgical site can cause the dripping of blood down the back of the throat, which results in frequent swallowing or clearing of the throat and indicates the client could be unstable. Based on the unstable versus stable priority setting framework and nursing knowledge, the client requires immediate intervention. This option is further supported by the ABC priority setting framework. 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 the client's 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 describes the most unstable client. An infant with a heart rate of 146/min and a respiratory rate of 28/min following a cleft palate repair needs to be evaluated further by the nurse; however, there is another client who is unstable and requires immediate intervention.

A nurse is caring for a client who is 48 hours postoperative following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent? A. Absent bowel sounds B. Serum BUN level 22 mg/dL C. Absent dorsalis pedis pulses D. Serum creatinine level of 1.3 mg/dL

C. Absent dorsalis pedis pulses Rationale: A. Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. A paralytic ileus is expected for 2 to 3 days following an abdominal aortic aneurysm repair and is indicated by the absence of bowel sounds. It is important for this finding to continue to be monitored because prolonged absence of bowel sounds can indicate a bowel infarction; however, this is not the most urgent finding. B. Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. BUN and creatinine levels should be checked daily following an abdominal aortic aneurysm repair to monitor renal function. A serum BUN level of 22 mg/dL is slightly above the expected reference range and requires continued monitoring; however, this is not the most urgent finding. C. Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. Using the urgent versus non-urgent priority setting framework, the most urgent finding is absent dorsalis pedis pulses. Absence of these pulses indicates that a graft occlusion following an abdominal aortic aneurysm repair is blocking circulation. 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. D. Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. BUN and creatinine levels should be checked daily following an abdominal aortic aneurysm repair to monitor renal function. A serum creatinine level of 1.3 mg/dL is slightly above the expected reference range and requires continued monitoring; however, this is not the most urgent finding.

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 from 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. Rationale: A. 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. Although administering an analgesic is an important action by the nurse, it is not the first action the nurse should take. B. 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. Although assisting the client to shift positions is an important action by the nurse, it is not the first action the nurse should take. C. 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. Pressure on the peroneal nerve can occur when skin traction is applied to lower extremities, which can result in foot drop. This can be manifested as a burning sensation under the traction bandage or boot. Reduced circulatory impairment can also result in the sensation of pain. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care. 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. Although distracting the client with music therapy is an important action by the nurse, it is not the first action the nurse should take.

A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurse's priority concern? A. Facial abrasions B. Penetrating head wound C. Incomplete amputation of the foot D. Tibia fracture requiring open reduction

C. Incomplete amputation of the foot Rationale: A. Answering this item requires application of the survival potential priority setting framework. Use of this framework is typically reserved for mass casualty situations, when resources are scarce and are allocated to save the greatest number of lives. While it might seem that the client least likely to survive should receive priority care, this is the client who is the lowest priority. The highest priority is assigned to the client who has injuries that are severe, but has the potential to survive with treatment. A client with facial abrasions should be assigned to the minimal triage category because treatment can be delayed for more than 2 hr without harm. This client should not be the nurse's priority concern. B. Answering this item requires application of the survival potential priority setting framework. Use of this framework is typically reserved for mass casualty situations, when resources are scarce and are allocated to save the greatest number of lives. While it might seem that the client least likely to survive should receive priority care, this is the client who is the lowest priority. The highest priority is assigned to the client who has injuries that are severe, but has the potential to survive with treatment. A client with a penetrating head wound should be assigned to the expectant triage category because survival is unlikely even with immediate and thorough treatment. This client should not be the nurse's priority concern. C. Answering this item requires application of the survival potential priority setting framework. Use of this framework is typically reserved for mass casualty situations, when resources are scarce and are allocated to save the greatest number of lives. While it might seem that the client least likely to survive should receive priority care, this is the client who is the lowest priority. The highest priority is assigned to the client who has injuries that are severe, but has the potential to survive with treatment. A client with an incomplete amputation of the foot should be assigned to the immediate triage category because injuries are life-threatening, but survivable if immediate care is received. The nurse should place highest priority on this client. D. Answering this item requires application of the survival potential priority setting framework. Use of this framework is typically reserved for mass casualty situations, when resources are scarce and are allocated to save the greatest number of lives. While it might seem that the client least likely to survive should receive priority care, this is the client who is the lowest priority. The highest priority is assigned to the client who has injuries that are severe, but has the potential to survive with treatment. A client who has a tibia fracture that requires an open reduction should be assigned to the delayed triage category because treatment can be delayed for up to 2 hr without harm. This client should not be the nurse's priority concern.

A nurse is caring for a toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse? A. Administer nebulized epinephrine (racemic epinephrine). B. Ensure adequate hydration. C. Obtain an oxygen saturation level. D. Encourage parents to comfort the client.

C. Obtain an oxygen saturation level. Rationale: A. 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. Nebulized epinephrine is appropriate for administration to a toddler who has laryngotracheobronchitis and is experiencing stridor at rest and retractions; however, there is another action the nurse should take first. B. 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. Because of insensible losses from increased respiratory effort and sweating, it is essential to ensure adequate hydration of a client who has laryngotracheobronchitis; however, there is another action the nurse should take first. C. 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. Laryngotracheobronchitis can result in impaired airway clearance because of upper airway swelling and increased respiratory effort. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care. 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. Respiratory effort is increased when the child is upset and crying. Encouraging parents to comfort a toddler who has laryngotracheobronchitis is appropriate; however, there is another action the nurse should take first.

A nurse is caring for a client who was admitted to the unit 3 hours ago following a total hip arthroplasty. Which of the following findings should be the nurse's priority concern? A. Urinary output of 75 mL over the past 3 hr B. 8-point elevation in the pre-surgery diastolic blood pressure C. Oxygen saturation of 90% on oxygen at 2 L per nasal cannula D. Core body temperature of 36.2° C (97.2° F)

C. Oxygen saturation of 90% on oxygen at 2 L per nasal cannula Rationale: A. Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. In the first 24 hr after surgery, urinary output is often decreased because of the effects of preoperative and anesthetic medications, stress from surgery, and fluid loss. Because the client is at risk for urinary retention, output should continue to be closely monitored; however, another finding is more urgent and should be the nurse's priority concern. B. Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. An elevated blood pressure is a potential complication following a surgical procedure. Because the client's blood pressure is increased from the baseline measurement, it should continue to be monitored, and the provider should be notified if the difference increases to more than a 15-point difference; however, another finding is more urgent and should be the nurse's priority concern. C. Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. Using the urgent versus non-urgent priority setting framework, the most urgent finding is an oxygen saturation of 90% on oxygen at 2 L per nasal cannula. Hypoxemia can be caused by a number of potentially life-threatening conditions in the postoperative period, such as atelectasis, pulmonary edema, or pulmonary embolism. Using the urgent versus non-urgent priority setting framework and nursing knowledge, this is the finding that represents the nurse's priority concern. D. Answering this item requires application of the urgent versus non-urgent priority setting framework. Using this framework, urgent needs are considered the priority need because they pose more of a threat to the client. It might also be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. Hypothermia is a potential complication following a surgical procedure. Because the client's temperature is below the expected reference range, it should continue to be monitored to ensure further reductions do not occur; however, another finding is more urgent and should be the nurse's priority concern.

A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first? A. A client who has COPD with an oxygen saturation of 90% B. A client who has diabetes mellitus with a HbA1C of 9% C. A client who has heart failure with 2+ pitting edema of the lower extremities D. A client who has a fever of 38.4° C (101.2° F) with tenderness in the right lower quadrant

D. A client who has a fever of 38.4° C (101.2° F) with tenderness in the right lower quadrant Rationale: A. 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. Nursing knowledge might also be needed to determine which option describes an acute need. COPD is a chronic condition that causes respiratory changes because of narrowing and obstruction of the airways, changes in chest size, and fatigue. Over time, the client compensates for these changes and can function with an oxygen saturation that is below the expected reference range. Because this could be considered a chronic problem, there is another client who has more acute needs that the nurse should evaluate first. B. 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. Nursing knowledge might also be needed to determine which option describes an acute need. Diabetes mellitus is a chronic condition and the HbA1C reflects the average blood glucose level over the prior 120 days. While this level is above the expected reference range, it does not warrant immediate intervention. Because this could be considered a chronic problem, there is another client who has more acute needs that the nurse should evaluate first. C. 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. Nursing knowledge might also be needed to determine which option describes an acute need. Heart failure is a chronic condition that results in fluid volume excess because of reduced cardiac output. Pitting edema of the lower extremities is a common manifestation of heart failure because the heart cannot sufficiently eject the blood being returned from the venous circulation, resulting in fluid retention. Because this could be considered a chronic problem, there is another client who has more acute needs that the nurse should evaluate first. D. 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. Nursing knowledge might also be needed to determine which option describes an acute need. Heart failure is a chronic condition that results in fluid volume excess because of reduced cardiac output. A fever of 38.4° C (101.2° F) with tenderness in the right lower quadrant is an acute finding that indicates possible appendicitis. Based on the acute versus chronic priority setting framework, this is the client the nurse should evaluate first.

A nurse in a provider's office is collecting data on a group of clients who are pregnant. Which of the following clients should be the nurse's priority concern? A. A client who is 26 weeks of gestation and reporting leukorrhea B. A client who is 10 weeks of gestation and reporting urinary frequency C. A client who is 37 weeks of gestation and reporting perineal discomfort D. A client who is 34 weeks of gestation and reporting abdominal tenderness

D. A client who is 34 weeks of gestation and reporting abdominal tenderness Rationale: A. 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 the client's 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 describes the most unstable client. Leukorrhea is a common discomfort associated with pregnancy that can occur throughout the pregnancy. While the client might need education regarding the common discomforts of pregnancy and self-care management, there is another client who is unstable and should be the nurse's priority concern. B. 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 the client's 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 describes the most unstable client. Urinary frequency is a common discomfort associated with pregnancy that can occur during the first and third trimesters. While the client might need education regarding the common discomforts of pregnancy and self-care management, there is another client who is unstable and should be the nurse's priority concern. C. 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 the client's 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 describes the most unstable client. Perineal discomfort is a common discomfort associated with pregnancy that can occur during the third trimester. While the client might need education regarding the common discomforts of pregnancy and self-care management, there is another client who is unstable and should be the nurse's priority concern. 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 the client's 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 describes the most unstable client. Abdominal, or uterine tenderness, is an early clinical finding associated with abruption placenta, which could lead to an unstable status. Based on the unstable versus stable priority setting framework and nursing knowledge, this is the client that should be the nurse's priority concern.

A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention? A. A client who has cystic fibrosis and has a paroxysmal cough B. A client who is prescribed cromolyn sodium (Crolom) and has a peak expiratory flow rate of 79% C. A client who has celiac disease and abdominal distention D. A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting

D. A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting Rationale: A. 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. Nursing knowledge might also be needed to determine which option describes an acute need. A paroxysmal cough is a clinical manifestation associated with cystic fibrosis, which is a chronic condition. While the client should be further evaluated, there is another client who has more acute needs that requires immediate intervention. B. 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. Nursing knowledge might also be needed to determine which option describes an acute need. Cromolyn sodium is a nonsteroidal anti-inflammatory medication used as an asthma prophylactic. A peak expiratory flow rate of 79% is below the expected rate and signals the possibility that asthma is not well-controlled. While the client should be further evaluated, there is another client who has more acute needs that requires immediate intervention. C. 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. Nursing knowledge might also be needed to determine which option describes an acute need. Abdominal distention results from impaired nutrient absorption and is a clinical manifestation associated with celiac disease, which is a chronic condition. While it is important to collect data regarding dietary intake and discuss appropriate dietary management, there is another client who has more acute needs that requires immediate intervention. D. 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. Nursing knowledge might also be needed to determine which option describes an acute need. Vomiting, slow heart rate, and anorexia are clinical findings associated with digoxin toxicity, which is an acute condition. Based on the acute versus chronic priority setting framework, this is the client that requires immediate intervention.

A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. For which of the following complications is it most important for the nurse to monitor? A. Diplopia B. Loss of bladder control C. Paresthesias D. Decreased respiratory effort

D. Decreased respiratory effort Rationale: A. Answering 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 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. Diplopia is an early manifestation of myasthenia gravis because of involvement of the ocular muscles. While it is important for the nurse to monitor for this complication, another complication is a higher priority. B. Answering 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 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. Loss of bladder and bowel control can occur as myasthenia gravis progresses. While it is important for the nurse to monitor for this complication, another complication is a higher priority. C. Answering 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 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. Paresthesias is painful tingling sensations affecting the hands, face, and thigh muscles, and is a clinical manifestation seen with myasthenia gravis. While it is important for the nurse to monitor for this complication, another complication is a higher priority. D. Answering 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 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. Using the ABC priority setting framework, maintaining a patent airway and ensuring adequate respiratory effort are priority concerns of the nurse caring for a client who has myasthenia gravis. Myasthenia gravis affects neuromuscular transmission of the voluntary muscles of the body. Progressive weakness of the diaphragmatic and intercostal muscles can produce respiratory distress. Based on this knowledge and using the ABC priority setting framework, it is most important for the nurse to monitor for respiratory difficulty.

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

D. Engage the client in physical activity. Rationale: A. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. Physical or chemical restraints should only be used when the safety of the client, staff, or others is at risk. Administering an anti-anxiety medication could become necessary if the client's anxiety level is not reduced and she becomes a threat to herself or others; however, there is a less restrictive action the nurse should take first. B. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. Physical or chemical restraints should only be used when the safety of the client, staff, or others is at risk. Taking the client to a place of seclusion might become necessary if the client's anxiety level is not reduced and she becomes a threat to herself or others; however, there is a less restrictive action the nurse should take first. C. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. Physical or chemical restraints should only be used when the safety of the client, staff, or others is at risk. Obtaining an order for soft wrist restraints might become necessary if the client's anxiety level is not reduced and she becomes a threat to herself or others; however, there is a less restrictive action the nurse should take first. D. Answering this item requires application of the least restrictive, least invasive priority setting framework. This framework assigns priority to nursing interventions that are least restrictive and least invasive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. Physical or chemical restraints should only be used when the safety of the client, staff, or others is at risk. Gross motor activities can reduce tension and lower anxiety levels. Using the least restrictive, least invasive priority setting framework, this action is less restrictive than others and should be the first action of the nurse.