Priority Setting Framework Advanced Test

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

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 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 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 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? Absent bowel sounds Serum BUN level 22 mg/dL Absent dorsalis pedis pulses Serum creatinine level of 1.3 mg/dL

Absent dorsalis pedis pulses 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 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? Administer an analgesic. Assist the client to shift positions. Check pedal pulse. Distract the client with music therapy.

Check pedal pulse 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 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?

Decreased respiratory effort

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 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

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?

Maternal respirations

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?

Perform fingersticks for glucose levels on client 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 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 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.

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?

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

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?

Promoting oxygenation 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,

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 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 preschooler who is postoperative following tonsillectomy and is experiencing frequent swallowing

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 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 and has had three episodes of vomitting 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 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

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

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 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.