Nurse logic 2.0 priority setting frameworks

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

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 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?

Check the heart rate and blood pressure

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?

Maintaining a patent airway

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

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

Platelets 95,000 mm3 Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed. 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.

Which of the following priority setting frameworks is being applied by a nurse who has decided to hang a client's intravenous antibiotic within 30 minutes of the time specified instead of giving another client their PRN pain medication?

Urgent vs. nonurgent

Which of the following can be used to help to determine the priority risk of a client who has multiple risks? (Select all that apply.)

aslow's Hierarchy of Needs Determining the complication that poses the highest risk Assessment of airway, breathing, and circulation needs

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 pt

A nurse is performing triage at a mass casualty event and is selecting a tag for a client who is severely injured and has no potential for survival. Which of the following tags should the nurse apply to the client?

class IV

nurse in a provider's office has collected data on four clients. Which of the following clients should be the nurse's priority concern?

client who is having a nosebleed associated with hypertension

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

hypoxic

A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first?

obtain an EKG

A nurse is caring for a client who is confused and disoriented. The client has been getting out of the wheelchair when in her room and going into the bathroom without assistance. Which of the following interventions would be the least restrictive but most effective to use with this client?

wheelchair alarm

An unstable client may be defined as one who fits which of the following descriptions?

A client whose newly placed tracheostomy is producing a large amount of secretions. airway

A nurse is caring for a client who is postoperative and whose airway is patent and respirations are 20 breaths per minute. Which of the following assessments should the nurse conduct in relation to the client's circulatory status? (Select all that apply

BP urinary output skun turgor pulse

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

Diarrhea

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

Digoxin 3.0ng/mL

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?

Immediate

A nurse is collecting data on four clients. Which of the following findings is the most urgent?

Warmth and pain in the calf

When using the nursing process priority setting framework, the nurse should always remember to do which of the following first?

assess the client

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

Which of the following statements explain why the needs of a client with a chronic illness are usually of lower priority than clients with an acute need?

Chronically ill clients have had the opportunity to physically adjust to their illness.

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?

Creating meaningful social relationships

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 patient

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?

Have the client position the head with the chin down while swallowing

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?

Move the client to room near the nurses station

Interventions that are least invasive are desirable because of which of the following? (Select all that apply.)

The number of organisms introduced into the body is reduced. The client's immune system may be compromised due to the stress of the illness. The use of equipment that penetrates the body's natural barriers increases the client's risk for infection.