Priority Setting and Frameworks Beginning & Advanced Test

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 COPD with an oxygen saturation of 90% A client who has diabetes mellitus with a HbA1C of 9% A client who has heart failure with 2+ pitting edema of the lower extremities A client who has a fever of 38.4° C (101.2° F) with tenderness in the right lower quadrant

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

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 26 weeks of gestation and reporting leukorrhea A client who is 10 weeks of gestation and reporting urinary frequency A client who is 37 weeks of gestation and reporting perineal discomfort A client who is 34 weeks of gestation and reporting abdominal tenderness

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

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

A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting 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 paroxysmal cough is a clinical manifestation associated with cystic fibrosis, which is a chronic condition 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, but this does not need as immediate interventions 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.

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? Diplopia loss of bladder control Paresthesias Decreased respiratory effort

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. Diplopia is an early manifestation of myasthenia gravis because of involvement of the ocular muscles. Loss of bladder and bowel control can occur as myasthenia gravis progresses. Paresthesias is painful tingling sensations affecting the hands, face, and thigh muscles, and is a clinical manifestation seen with myasthenia gravis.

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. Place the client on bed rest. Encourage increased fluid intake. Initiate continuous ECG monitoring.

Evaluate level of consciousness. 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.

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? Promote adequate intake of calcium. Evaluate neurovascular status. Elevate the extremity above the heart. Apply ice intermittently for the first 24 hr.

Evaluate neurovascular status. 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.

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

Obtain an ECG Answering this item requires consideration of Maslow's Hierarchy of Needs Obtaining an ECG will assist in determining the presence of dysrhythmias related to a serum potassium level below the expected reference range. According to Maslow's Hierarchy of Needs priority setting framework, physiological needs, such as adequate cardiac functioning, receive highest priority. This action is further supported by the ABC priority setting framework due to the impact of cardiac function on circulation.

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? Administer nebulized epinephrine (racemic epinephrine). Ensure adequate hydration. Obtain an oxygen saturation level. Encourage parents to comfort the client.

Obtain an oxygen saturation level. 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. Nebulized epinephrine is appropriate for administration to a toddler who has laryngotracheobronchitis and is experiencing stridor at rest and retractions; Because of insensible losses from increased respiratory effort and sweating, it is essential to ensure adequate hydration of a client who has laryngotracheobronchitis; Respiratory effort is increased when the child is upset and crying. Encouraging parents to comfort a toddler who has laryngotracheobronchitis is appropriate;

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? Bathe a client who is scheduled for physical therapy at 9 a.m. Perform fingersticks for glucose levels on clients who have diabetes mellitus. Stock procedure rooms. Distribute clean linens.

Perform fingersticks for glucose levels on clients who have diabetes mellitus. 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.

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 Management of pain Maintaining hydration Preventing infection

Promoting oxygenation 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. Analgesics should be administered to the client to manage pain during a vaso-occlusive crisis; Hydration should be maintained through oral and IV therapy for a client in vaso-occlusive crisis; 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 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 CPR d. Announce a code

a. Check on the client 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. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. If the client is able to be aroused or a pulse is palpated, then the client is not in cardiac arrest, and there is a problem with the monitoring equipment. It is common for leads to become loose or fall off clients when they move around, resulting in the monitor detecting an absence of cardiac function. Therefore, checking on the client is the first action the nurse should take.1

A newly hired nurse is reviewing the facility's emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide priority care to clients who are in which of the following categories during a disaster? a. Immediate b. Delayed c. Minimal d. Expectant

a. Immediate 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 with injuries that are severe, but has the potential to survive with treatment. Clients assigned to the immediate triage category in a mass casualty event have life-threatening, but survivable injuries if immediate care is received. Based on the survival potential priority setting framework, the nurse should provide priority care to clients in this category. Clients assigned to the minimal triage category in a mass casualty situation can wait several hours to days before receiving care. The nurse should not provide priority care to clients in this category. Clients assigned to the expectant triage category in a mass casualty situation are not expected to survive and are provided comfort measures only. The nurse should not provide priority care to clients in this category. Clients assigned to the delayed triage category in a mass casualty event have significant injuries, but can wait up to 2 hr before receiving care. The nurse should not provide priority care to clients in this category.

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 b. Administer solifenacin (Vesicare) c. Insert an indwelling urinary catheter d. Perform intermittent catheterization

a. Initiate a bladder training schedule 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 Fetal heart rate should be monitored before and during magnesium therapy; Deep-tendon reflexes should be evaluated during magnesium therapy. Absent deep-tendon reflexes are associated with magnesium toxicity; 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;

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 HR c. Maternal deep-tendon reflexes d. Maternal urinary output

a. Maternal respirations 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.

A nurse 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 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. Evidence-based practice and current recommendations of the American Academy of Pediatrics include positioning the infant supine while sleeping. This intervention has had the greatest impact on reducing the occurrence of SIDS. Using the safety and risk reduction priority setting framework and nursing knowledge, this is the priority information to include in the discharge teaching.

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 Bowel sound Serum BUN level 22 mg/dL absent dorsalis pedis pulses serum creatinine level of 1.3 mg/dL

absent dorsalis pedis pulses 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. 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; 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; A serum creatinine level of 1.3 mg/dL is slightly above the expected reference range and requires continued monitoring;

A nurse has been assigned to care for four clients on a med-surg 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 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. Redness and swelling at the edges of the incision are expected clinical findings 48 hr after abdominal surgery. Nausea and vomiting are common clinical findings associated with cholecystitis. This hemoglobin level is below the expected reference range; however, the client's problem is being addressed by receiving a transfusion.

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? a. Obtain an arterial pH level b. Check the heart rate and blood pressure c. Insert an indwelling catheter d. Collect a serum BUN and creatinine

b. Check the heart rate and blood pressure 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 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 is assisting with the admissions 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 and extremity elevation

b. Check the leg for warmth and edema 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. If warmth and edema is found in the leg, this indicates that the decreased circulation could be due to a deep-vein thrombosis. Based on this information, appropriate interventions can be determined and implemented as a part of the plan of care.

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 with ambulation when indicated b. Determine the mobility status of each client c. Maintain the side rails of each bed in raised position d. Plan a fall prevention program for clients at risk

b. Determine the mobility status of each client 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. 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 conducting therapeutic medication monitoring on four clients. Which of the following findings should be immediately reported to the provider? a. Lithium carbonate 0.8 mEq/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 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 their 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 poses the greatest risk to the client. This digoxin level is above the expected reference range and indicates digoxin toxicity. Based on the unstable versus stable priority setting framework and nursing knowledge, this lab value is the priority and should be immediately reported to the provider.

Following morning report, a nurse assigns completion of several tasks to an assertive personnel (AP). Which of the following tasks should the nurse have the AP perform first? a. Bathe a client who is scheduled for a 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

A nurse is caring for a client who is having difficultly 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 suctioning

b. Place the client in the orthopneic position 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. 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 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 c. Potassium 3.5 mEq/L

b. Platelets 95,000 mm^3 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 their survival. Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening needs that should be addressed. 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 poses the greatest risk to the client. 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.

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 (maslow, 4th level) b. Preventing injury (maslow, 5th level) c. Encouraging problem solving (maslow, 5th level) d. Promoting usefulness (maslow, 4th level)

b. Preventing injury 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.

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 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 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.

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. An adolescent who is postoperative following an appendectomy and has refused to ambulate for the past 8 hrs b. A school-aged 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 HR of 146/min and a RR of 28/min

c. A preschooler who is postoperative following a tonsillectomy and is experiencing frequent swallowing 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. An adolescent who refuses to ambulate following abdominal surgery needs additional education and encouragement An infiltrated peripheral IV needs to be discontinued and another IV started; . 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;

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? 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 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.

A nurse is 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 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 third level of Maslow's Hierarchy of Needs includes love, affection, and social relationships in fulfilling love and belonging needs. Social relationships are a component of friendship, which would be included in the third level of Maslow's Hierarchy of Needs. Based on Maslow's Hierarchy of Needs, this is the client's priority need.

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 ​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. Hypoxemia indicates reduced blood oxygen levels, which involves the physiological needs of the client and is the first level of Maslow's Hierarchy of Needs. Because oxygen is considered the most basic physiological need, this is the need the nurse should address first. This is further supported using the ABC priority setting framework.

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? a. Providing pain control b. Preventing hemorrhage c. Maintaining a patent airway d. Ensuring adequate fluid intake

c. Maintaining a patent airway 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 that 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 is the nurse's priority action for a client who is in the immediate postoperative period following a tracheotomy. An airway obstruction is a potential complication for clients following head and neck surgery secondary to production of mucus and need for suctioning. Based on this knowledge and using the ABC priority setting framework, the nurse's priority action is to maintain a patent airway.

A nurse is collecting data on four clients. Which of the following findings is the most urgent? a. Bladder distention and urgency b. Pedal edema c. Warmth and pain in the calf d. Hypoactive bowel sounds

c. Warmth and pain in the calf 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 warmth and pain in the calf of a client. Warmth and pain in the calf is indicative of deep-vein thrombosis, which places the client at risk for pulmonary embolism. 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.

A nurse in a rehabilitation 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. A client who has depression and is easily distracted c. A client who has Alzheimer's disease and is unable to complete activities of daily living d. A client who had abdominal surgery 10 ago and reports feeling his incision pop

d. A client who had abdominal surgery 10 ago and reports feeling his incision pop 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. Wound dehiscence or evisceration most commonly occurs 3 to 11 days following surgery and can be caused by not splinting the surgical site when moving, forceful coughing, vomiting, or straining. Clients often report feeling the incision "pop," indicating either dehiscence or evisceration has occurred. Based on the acute versus chronic priority setting framework, the nurse should evaluate this client first.

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 has a hx of heart failure b. A client who has type 1 diabetes mellitus c. A client who is reporting pain associated with osteoarthritis of the knees d. A client who is having a nosebleed associated with hypertension

d. A client who is having a nosebleed associated with hypertension 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. A nose bleed, or epistaxis, is an acute condition requiring immediate intervention to prevent further blood loss. Additionally, this finding can be associated with a blood pressure that is above the expected reference range, indicating the need for further intervention. Based on the acute versus chronic priority setting framework, this client should be the nurse's priority.

A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's SpO2 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 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 the highest priority because the airway must be open and clear 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. 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 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 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 the highest priority because the airway must be open and clear 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 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 experiencing panic level of anxiety. Which of the following actions should the nurse take first? a. Administer an anti-anxiety medication b. Take the client to a plave of seclusion c. Obtain an order for soft wrist restraints d. Engage the client in physical activity

d. Engage the client in physical activity 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. 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; 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; 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;

A nurse is preparing to administer oral medications to a client who has unilateral weakness following a CVA. Which of the following be the priority action of the nurse? a. Administer medications with meals when possible b. Ensure client understanding of medication's effects c. Determine the client's ability to self-administer medications d. Have the client position the head with the chin down while swallowing

d. Have the client position the head with the chin down while swallowing 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. Clients are at risk for aspiration following a CVA, and having the client position the head with the chin down while swallowing reduces this risk. Based on the safety and risk reduction priority setting framework, this should be the nurse's priority action. Preventing aspiration is further supported as the priority by the ABC priority setting framework.

A nurse is caring for a client who has a UTI. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first? a. Ensure all four side rails are up b. Administer a prescribed sedative c. Place the client in a 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 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 physical restraints. Physical restraints should only be used when the safety of the client, staff, or others is at risk. Moving the client to a room near the nurses' station allows for more frequent observation and promotes client safety. Using the least restrictive, least invasive priority setting framework, this action is less restrictive than the other actions and should be the nurse's first action.

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? Facial abrasions Penetrating head wound incomplete amputation of the foot tibia fracture requiring open reduction

incomplete amputation of the foot 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.

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 nurse's priority concern? Urinary output of 75 mL over the past 3 hr 8-pt elevation in the pre-surgery diastolic blood pressure oxygen saturation of 90% on oxygen at 2 L per nasal cannula Core body temperature of 36.2 C (97.2 F)

oxygen saturation of 90% on oxygen at 2 L per nasal cannula 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. 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; 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 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;