Priority Setting Framework (Adv)
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 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 client who has a fever of 38.4°C (101.2°F) with tenderness in right lower quadrant 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.
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 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.
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 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 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 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.
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 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 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 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 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 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.
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 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. - 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.
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 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?
Evaluate neurovascular status 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 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 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 client with a penetrating head wound should be assigned to the expectant triage category because survival is unlikely even with immediate and thorough treatment. This client should not be the nurse's priority concern. - A client who has a tibia fracture that requires an open reduction should be assigned to the delayed triage category because treatment can be delayed for up to 2 hr without harm. This client should not be the nurse's priority concern.
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 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.
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 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 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 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; however, there is another action the nurse should take first.
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 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.
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 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 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 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 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 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.
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 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.
