ATI - NurseLogic Priority Setting Frameworks Beginner

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

Warmth and pain in the calf I want some pain in the calf is indicative of deep vainthrombosis which place is the client at risk for pulmonary embolism

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 ? Administer an anticoagulant . Check the leg for warmth and edema . Apply elastic stockings . Promote bed rest and extremity elevation .

Check the leg for warmth and edema . Edema is found in the leg circulation could be due to a deep vein thrombosis

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 ? Initiate oxygen therapy . Encourage an increase in oral fluids . Provide room humidification . Assist client to cough effectively .

Assist client to cough effectively . Assisting the client to cough affectively open the airway by removing secretions as follows ABC setting framework

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 ? Check on the client . Unlock the crash cart . Begin cardiopulmonary resuscitation Announce a code .

Check on the client . This requires application of nursing process priority setting framework beginning with assessment, collect adequate data from the client, you can formulate a plan of action, implementation a nursing intervention , or notifying a provider of a change in the clients condition. If the client is able to be aroused or false is palpated and the client is not in cardiac arrest and there is a problem with the monitoring equipment. Carmen call of clients when they move around resulting in the monitor detecting an absence of cardiac function this is why checking on the client is the first action a nurse must take

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

Check the heart rate and blood pressure . What is the least invasive priority intervention center not invasive to the client should be taken before interventions that are invasive this reduces the number of organisms introduced into the body decrease in the number of hospital acquired infections and increase in heart rate and decrease in blood pressure are consistent with a fluid volume deficit

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

Determine the mobility status of each client . Determining the mobility status of each client will help to identify those patients who are at risk for falls in mentation of education and prevention effort specific to the needs of each client

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

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 with vital signs are or laboratory values indicate a risk for becoming unstable are also a higher priority than clients who are stable this digoxin level is above the expected reference range and indicates digoxin toxicity. This lab value is the priority and should be immediately report to the provider

A nurse is caring for a newly admitted client . Which of the following client needs should the nurse address first ? Homelessness Lack of family support Hypoxic Under nourished

Hypoxic 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 oxygen is the most basic physiological need and should be addressed first

A nurse is caring for a client who is having difficulty breathing . Which of the following actions should the nurse take first ? Place 02 at 2 L per nasal canula on the client Place the client in the orthopneic position . Perform chest percussion . Perform nasotracheal suctioning .

Place the client in the orthopneic position . Play some the client in the orthopneic position allows for maximum chest expansion which improves respiratory effort

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

Diarrhea ABC's Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood volume this influences circulation causing this to be highest priority finding

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

Maintaining a patent airway ABC's this question emphasizes the function haven't open airway being able to breathe in adequate amount of oxygen and circulating that oxygen to the bodies organs via the blood. And every instruction is a potential complication for clients following head end neck surgery secondary to production of mucus and need for suctioning

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 ? Immediate Delayed Minimal Expectant

Immediate Well 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 an immediate triage category and a mass casualty event have life-threatening but survivable injuries is immediate care is received

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

A client who had abdominal surgery 10 days ago and reports feeling his incision pop is important to attend to alterations when they are in the acute phase so they don't escalate into life-threatening events wound dehiscence or evisceration most commonly occurs 3 to 11 days following surgery and can be caused by not splitting the surgical site when moving forcefully coughing vomiting or straining clients option report feeling the incision Pop indicating either dehiscence or evisceration has occurred Numbness of the toes is caused by decreased circulation in clients who have peripheral vascular disease well this report should be evaluated further there is another client with a more acute need the nurse should evaluate 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 client who has a history of heart failure A client who has type 1 diabetes mellitus A client who is reporting pain associated with osteoarthritis of the knees A client who is having a nosebleed associated with hypertension

A client who is having a nosebleed associated with hypertension A nosebleed or epistaxes is an acute condition requiring immediate intervention to prevent further blood loss additionally the spine and can be associated with a blood pressure that is above the expected reference range indicating the need for further intervention

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 ? Establishing a sense of achievement Contributing to society Creating meaningful social relationships Enhancing self - confidence

Creating meaningful social relationships Consider Maslow's hierarchy of needs the first level consist 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 the fifth level consists of achieving full potential and ability to problem solve and cope with life situations physiological needs to take precedence and should be reviewed first client needs should than be addressed by following the remaining for hierarchical levels

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

Have the client position the head with the chin down while swallowing . Clients are at risk for aspiration following a CVA having the client position ahead with the chin down while swallowing reduces this risk. Preventing aspiration is further supported as a priority by the ABC priority setting framework

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

Move the client to a room near the nurses ' station . Requires application of the least restrictive least invasive priority setting framework is framework assigned 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 with the client staff or others is at risk moving the clients to a room near the nurses station allows for more frequent observation and promotes client safety

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 ? Obtain an ECG . Administer oral potassium . Encourage potassium - rich foods . Monitor 1 & 0 .

Obtain an ECG . Obtaining an EKG 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 function receive highest priority this action is further supported by the ABC priority setting framework

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 ? Place the infant in a supine position when sleeping . Place the infant on a firm mattress when sleeping . Avoid covering the infant with loose bedding while sleeping . Avoid leaving stuffed animals in the crib with the sleeping infant .

Place the infant in a supine position when sleeping . Evidence based practice and current recommendations of the American Academy of pediatrics include positioning the infant supine while sleeping intervention has the greatest impact on reducing the occurrence of SIDS using the safety and risk reduction priority setting framework and nurse knowledge this is the priority

A nurse is reviewing the lab results for four clients . The client with which of the following values requires immediate intervention ? Cholesterol 220 mg / dL Platelets 95,000 mm³ BUN 20 mg / dL Potassium 3.5 mEq / L

Platelets 95,000 mm³ This platelet level is below the expected reference range and indicates the client is at risk for bleeding