Priority Setting Framework (Adv)
A nurse working the 7 p.m. to 7 a.m. shift on the pediatric unit has received report on four postoperative clients. Which of the following requires immediate intervention?
A preschooler who is postoperative following a tonsillectomy and is experiencing frequent swallowing.
A nurse is caring for a client who is 48 hr postoperative following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent?
Absent doralis pedis pulse
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?
Incomplete amputation of the foot
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?
Initiate a bladder training schedule
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 of 0 to 10 under the traction bandage. Which of the following actions should the nurse take first?
Check pedal pulse
A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention
A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting
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 client following knee replacement surgery complaint of pain and warmth in the calf
A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first?
A client who has a fever of 38.4°C (101.2°F) with tenderness in right lower quadrant
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 client who is 34 weeks of gestation and reporting abdominal tenderness
A nurse is collecting data on a client who has a diagnosis of myasthenia graves. For which of the following complications is it most important for the nurse to monitor?
Decreased respiratory effort
A nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first?
Engage the client in physical activity
A nurse is caring for a client who has a fractured hip and a respiratory rate of 26/min. Which of the following actions should the nurse take first?
Evaluate level of consciousness
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?
Evaluate neurovascular status
A nurse if 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?
Maternal respirations
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?
Obtain an oxygen saturation level
A nurse is caring for a client who was admitted to the unit 3 hr ago following a total hip arthroplasty. Which of the following findings should be the nurse's priority concern?
Oxygen saturation of 90% on oxygen at 2 L per nasal cannula
Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first?
Perform fingersticks for glucose levels on clients who have diabetes mellitus
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?
Preventing injury
A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occulsive crisis. Which of the following is the nurse's priority concern?
Promoting oxygenation
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?
Use a properly-fitted bicycle helmet
