ATI Nurse Logic 2.0: Priority Setting Frameworks

A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen sat lvl is 90% on room air. Which of the following actions should the nurse take first?

Assist client to cough effectively Assisting the client to cough effectively opens the airway by removing secretions. Based on the ABC priority setting framework, this is the first action the nurse should take because a clear airway is necessary for oxygen exchange to occur.

A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for a fluid volume deficit?

Check the hear rate and BP An increase in heart rate and decrease in blood pressure are consistent with a fluid volume deficit. Using the least restrictive, least invasive priority setting framework, this action is less invasive than the other actions and should be the nurse's first action.

A nurse in a long-term are facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following should the nurse take first?

Determine the mobility status of each 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. Determining the mobility status of each client will help to identify those patients who are at risk for falls. This knowledge will ensure the implementation of education and prevention efforts specific to the needs of each client. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

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

Diarrhea Using the ABC priority setting framework, maintaining circulation is the nurse's priority concern. Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood volume. Based on this knowledge and using the ABC priority setting framework, this is the highest priority finding by the nurse.

A nurse is caring for a client who is in the immediate postoperative period following a tracheotomy. Which of the following is the nurse's priority action?

Maintaining a patient 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 Placing the client in the orthopneic position allows for maximum chest expansion, which improves respiratory effort. Based on the least restrictive, least invasive priority setting framework, this should be the first action the nurse takes.

A nurse is reviewing the lab results for 4 clients. The client with which of the following values requires immediate intervention?

Platelets 95,000mm3

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

Warmth and pain in the calf