NurseLogic 2.0-Priority Setting Framework 1 & 2

A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take? A) Administer an anticoagulant B) Check the leg for warmth and Edema C) Apply elastic stockings D) Promote bed rest & extremity elevation

B) Check the leg for warmth and Edema

A nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be immediately reported to the provider? A) Lithium carbonate 0.8 mmol/L B) Digoxin 3.0 ng/mL C) Peak serum gentamicin 6 mcg/mL D) Magnesium sulfate 4 mEq/L

B) Digoxin 3.0 ng/mL Therapeutic serum digoxin levels range from 0.5-2 ng/mL.

A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first? A) Place O2 at 2 L per nasal canula on the client B) Place the client in the orthopneic position C) Perform chest percussion D) perform nasotracheal suction

B) Place the client in the orthopneic position

A nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention? A) Cholesterol 220 mg/dL B) Platelets 95,000 mm^3 C) BUN 20 mg/dL D) Potassium 3.5 mEq/L

B) Platelets 95,000 mm^3 A normal platelet count ranges from 150,000 to 450,000 platelets per mm^3.

A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for fluid volume deficit? A) obtain an arterial pH level B) check the HR and BP C) insert an indwelling catheter D) collect a serum BUN and creatinine

B) check the HR and BP

A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first? A) Provide assistance w/ ambulation when indicated B) determine the mobility status of each patient C) Maintain the side rails of each be in the raised position D) Plan a fall prevention program for clients at risk

B) determine the mobility status of each patient

A nurse has been assigned four patients on a med surge floor. which pt should the nurse evaluate first? A. a client 48 hr after abd surgery with redness and swelling at the edges of the incision B. a client following knee replacement surgery complaining of warmth and pain in the calf C. a client admitted with cholecystitis who reports frequent nausea and vomiting D. a client admitted with GI bleed receiving packed RBCs for a hemoglobin of 7.8

B. a client following knee replacement surgery complaining of warmth and pain in the calf

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 level of the heart D. apply ice intermittently for the first 24hr

B. evaluate neurovascular status

Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). which tasks should the nurse have the AP do first? A. bathe a client who is scheduled for PT at 9am B. perform fingersticks for glucose levels on clients with DM C. stock procedure rooms D. distribute clean linens

B. perform fingersticks for glucose levels on clients with DM

A nurse is caring for a client who is newly diagnosed with bipolar disorder and is currently experiencing an acute manic episode. what is the priority action? A. enhancing self esteem B. preventing injury C. encouraging problem solving D. promoting usefulness

B. preventing injury

A 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 bike B. use a properly fitted helmet C. wear light colored clothing at night D. use hand signals when turning

B. use a properly fitted helmet

A nurses caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client? A) establishing a sense of achievement B) contributing to society C) creating meaningful social relationships D) enhancing self- confidence

C) Creating meaningful social relationships Framework: Maslows Hierarchy of needs Social relationships are a component of friendship, which would be included in the 3rd level.

A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first? A) homelessness B) lack of family support C) Hypoxic D) under nourished

C) Hypoxic

A nurses caring for a client who is in the immediate post operative period following a tracheotomy. Which of the following is the nurses priority action? A) providing pain control B) preventing hemorrhage C) maintaining a patent airway D) ensuring adequate fluid intake

C) maintaining a patent airway

A nurse is collecting data on four clients. Which of the following findings is the most urgent? A) bladder distension and urgency B) pedal edema C) warmth and pain in the calf D) hypoactive bowel sounds

C) warmth and pain in the calf

A nurse is caring for a client who was admitted to the unit 3 hr ago following total hip arthroplasty. which finding is the priority concern? A. urinary output of 75ml over the past 3 hours B. 8 point elevation in the pre surgery diastolic bp C. O2 sat of 90% on 2L nasal cannula D. core body temp of 97.2

C. O2 sat of 90% on 2L nasal cannula

A nurse working the 7am to 7pm shift on the ped unit has received report on four post op clients. which requires immediate intervention? A. an adolescent who is postop following an appendectomy and has refused to ambulate for the last 8hr B. a school aged child who is post op following a herniorrhaphy with an infiltrated IV that has been clamped C. a preschooler who is post op following a tonsillectomy that has frequent swallowing D. an infant who is post op following a cleft palate repair with a HR of 146 and RR 28

C. a preschooler who is post op following a tonsillectomy that has frequent swallowing

A nurse is caring for a client who is 48 hr postop following an abdominal aortic aneurysm resection. which finding is most urgent? A. absent bowel sounds B. serum BUN level 22 C. absent dorsalis pedis pulses D. serum creatinine level 1.3

C. absent dorsalis pedis pulses

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 0-10 scale under the traction bandage. which action should the nurse take first? A. administer analgesic B. assist the client to shift positions C. check pedal pulse D. distract the client with music therapy

C. check pedal pulse

A public health nurse is triaging clients at the site of an explosion. the client with what injury 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

A nurse is caring for a toddler who has laryngotracheobronchitis and is having difficulty breathing. which is the first action a nurse should take? A. administer nebulized epinephrine B. ensure adequate hydration C. obtain O2 sat D. encourage parents to comfort the client

C. obtain O2 sat

A newly hired nurse is reviewing the facilities emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide power you care to clients who are in which of the following categories during a disaster? A) immediate B) delayed C) minimal D) expectant

A) immediate

A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. which complication is most important for the nurse to monitor? A. decreased respiratory effort B. diplopia C. loss of bladder control D. paresthesias

A. decreased respiratory effort

A nurse is caring for a client who has a fractured hip and a respiratory rate of 26/min. which action should the nurse take first? A. evaluate level of consciousness B. place client on bed rest C. increase in fluid intake D. initiate continuous ECG monitoring

A. evaluate level of consciousness

A nurse is caring for a client who has a flaccid bladder following a spinal cord injury. which action should the nurse take first? A. initiate bladder training schedule B. administer vesicare C. insert foley D. perform intermittent straight cath

A. initiate bladder training schedule

A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. which of the following data is most important for the nurse to monitor? A. maternal respirations B. fetal HR C. maternal deep tendon reflexes D. maternal urinary output

A. maternal respirations

A nurse is caring for a child who has sickle cell dz and has been admitted in a vaso-occlusive crisis. what is the nurse's priority concern? A. promoting oxygenation B. managing pain C. maintaining hydration D. preventing infection

A. promoting oxygenation

A nurses caring for a client who has a urinary track infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first? A) Ensure all 4 side rails are up. B) Administer a prescribed sedative. C) Place the client in soft wrist restraints D) Move the client to a room near the nurses' station

D) Move the client to a room near the nurses' station

A nurse in a provider's office has collected data on four clients. Which of the following clients should be the nurse's priority concern? A) a client who is has a history of HF B) a client who has type 1 DM C) a client who is reporting pain associated w/ osteoarthritis of the knees D) a client who is having a nosebleed associated w/ hypertension

D) a client who is having a nosebleed associated w/ hypertension

A nurse is preparing to administer oral medication to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse? A) Administer medications w/ meals when possible B) Ensure client understanding of medication's effects C) Determine the client's ability to self-administer meds D) have the client position the head w/ chin down while swallowing

D) have the client position the head w/ chin down while swallowing

A nurse in a provider's office is collecting data on a group of clients who are pregnant. which client should be the nurse's priority concern? A. A client who is 26 weeks gestation and is reporting leukorrhea B. A client who is 10 weeks gestation and is reporting urinary frequency C. A client who is 27 weeks gestation and is reporting perianal discomfort D. A client who is 34 weeks gestation and is reporting abdominal tenderness

D. A client who is 34 weeks gestation and is reporting abdominal tenderness

A nurse is caring for a group of ped clients. which client requires immediate intervention? A. client who has cystic fibrosis and has a paroxsymal cough B. a client who is prescribed cromolyn sodium and has a peak expiratory rate of 79% C. a client who has celiac disease and abdominal distention D. a client who is prescribed digoxin and has had 3 episodes of vomiting

D. a client who is prescribed digoxin and has had 3 episodes of vomiting

A nurse on a medical unit has received report on four clients. which client should the nurse evaluate first? A. client with COPD and O2 saturation of 90% B. client with DM and HbA1C of 9% C. client who has HF with 2+ pitting edema in lower extremities D. client who has a fever of 38.4 C (101.2 F) with tenderness in the right lower quadrant

D. client who has a fever of 38.4 C (101.2 F) with tenderness in the right lower quadrant

A nurse is caring for a pt who is experiencing panic level anxiety. which of the following actions should the nurse take first? A. administer anti anxiety medication B. take the client to a place of seclusion C. obtain order for soft wrist restraints D. engage the client in physical activity

D. engage the client in physical activity

A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first? A) Check on the client B) unlock the crash cart C) begin cardiopulmonary resuscitation D) announce a code

A) Check on the client

A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first? A) Obtain an ECG. B) Administer oral potassium C) Encourage potassium-rich foods D) Monitor I & O

A) Obtain an ECG. Obtaining an ECG will assist in determining the presence of dysrhythmias related to a serum potassium level below the expected reference range.

A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions? A) Place the infant in a supine position when sleeping B) place the infant on a firm mattress when sleeping C) avoid covering the infant with loose bedding while sleeping D) avoid leaving stuffed animals in the crib with the sleeping infant

A) Place the infant in a supine position when sleeping

A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first? A) A client who has peripheral vascular disease and reports numbness in the toes B) client who has depression & is easily distracted C) A client who has Alzheimer's disease and is unable to complete ADLS D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop

D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop

A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first? A) Initiate oxygen therapy B) encourage an increase in oral fluids C) provide room humidification D) Assist client to cough effectively

D) Assist client to cough effectively

A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse? A) Malaise B) Anorexia C) Headache D) Diarrhea

D) Diarrhea ABC framework C=circulation Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood volume.