Priority Setting Framework Advanced Test

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. 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

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

A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first? A. A client who has COPD with an oxygen saturation of 90% B. A client who has diabetes mellitus with a HbA1C of 9% C. A client who has heart failure with 2+ pitting edema of the lower extremities D. 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 with tenderness in the right lower quadrant 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.

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

A client who is 34 weeks gestation and reporting abdominal tenderness

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

A client who is prescribed digoxin and has had three episodes of vomitting

A nurse working the 7pm to 7am 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 hr B. A school-age 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 heart rate of 146/min and a respiratory rate of 28/min

A preschooler who is postoperative following tonsillectomy and is experiencing frequent swallowing

A nurse is caring for a client who is 48 hrs postoperative following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent? A. Absent bowel sounds B. Serum BUN level 22 mg/dL C. Absent dorsalis pedis pulses D. Serum creatinine level of 1.3 mg/dL

Absent dorsalis pedis pulses

A nurse is caring for a client who has a compound fracture of the tibia and fibula and is in the 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.

Check pedal pulse

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? A. Diplopia B. Loss of bladder control C. Paresthesias D. Decreased respiratory effort

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? A. Administer an anti-anxiety medication. B. Take the client to a place of seclusion. C. Obtain an order for soft wrist restraints. D. Engage the client in physical activity.

Engage the client in physical activity 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.

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? A. Evaluate level of consciousness. B. Place the client on bed rest. C. Encourage increased fluid intake. D. Initiate continuous ECG monitoring.

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

Evaluate neurovascular status

*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? A. Facial abrasions B. Penetrating head wound C. Incomplete amputation of the foot D. Tibia fracture requiring open reduction

Incomplete amputation of the foot 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. Tibia fracture requiring open reduction

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.

Initiate a bladder training schedule

*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 heart rate C. Maternal deep-tendon reflexes D. Maternal urinary output*

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

Obtain an oxygen saturation level

A nurse is caring for a client who was admitted to the unit 3 hours ago following a total hip arthroplasty. Which of the following findings should be the nurse's priority concern? A. Urinary output of 75 mL over the past 3 hr B. 8-point elevation in the pre-surgery diastolic blood pressure C. Oxygen saturation of 90% on oxygen at 2 L per nasal cannula D. Core body temperature of 36.2° C (97.2° F)

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. Which of the following tasks should the nurse have the AP perform first? A. Bathe a client who is scheduled for 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.

Perform fingersticks for glucose levels on client 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? A. Enhancing self-esteem B. Preventing injury C. Encouraging problem solving D. Promoting usefulness

Preventing injury

A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern? A. Promoting oxygenation B. Management of pain C. Maintaining hydration D. Preventing infection

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? 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.

Use a properly-fitted bicycle helmet