ATI: Critical Thinking/Clinical Reasoning/Clinical Judgment: Nursing Proces
and Priority Setting
Study online at https://quizlet.com/_h9qj40
1. A nurse is preparing to apply a condom catheter to a client who has a penis.
Which of the following actions should the nurse take next after performing
hand hygiene and applying clean gloves?
A. Provide perineal care to the client
B. Prepare the drainage bag and tubing
C. Check the condition of the penile shaft
D. Place a bath blanket over the client's upper torso: C. Check the condition of the penile
shaft
2. A nurse is the PACU is caring for a client who is postoperative following
an abdominal hysterectomy. Which of the following actions should the nurse
take first?
A. Encourage the client to cough and deep breathe
B. Change the client's perineal pad
C. Place the client in a side-lying position
D. Monitor the client's urinary output: C. Place the client in a side-lying position
The greatest risk to the client is injury from an obstructed airway; therefore, the first action the nurse should take is
to place the client in a side-lying position to allow their tongue to fall to the side of their mouth to prevent the tongue
from obstructing their airway.
3. A nurse is assessing a client who has cancer and is receiving morphine for
pain management. Which of the following findings is the nurse's priority?: Res-
piratory rate 10/min
Using the airway, breathing, circulation approach to client care, the nurse should identify that a respiratory rate of
10/min is the priority finding. A respiratory rate of 10/min is an indication of opioid toxicity. The nurse should withhold
the next dose of the medication and notify the provider immediately.
4. A nurse is assessing four clients. Which of the following clients should the
nurse assess first?
A. A client who has COPD and a respiratory rate of 23/min
1/2
and Priority Setting
Study online at https://quizlet.com/_h9qj40
1. A nurse is preparing to apply a condom catheter to a client who has a penis.
Which of the following actions should the nurse take next after performing
hand hygiene and applying clean gloves?
A. Provide perineal care to the client
B. Prepare the drainage bag and tubing
C. Check the condition of the penile shaft
D. Place a bath blanket over the client's upper torso: C. Check the condition of the penile
shaft
2. A nurse is the PACU is caring for a client who is postoperative following
an abdominal hysterectomy. Which of the following actions should the nurse
take first?
A. Encourage the client to cough and deep breathe
B. Change the client's perineal pad
C. Place the client in a side-lying position
D. Monitor the client's urinary output: C. Place the client in a side-lying position
The greatest risk to the client is injury from an obstructed airway; therefore, the first action the nurse should take is
to place the client in a side-lying position to allow their tongue to fall to the side of their mouth to prevent the tongue
from obstructing their airway.
3. A nurse is assessing a client who has cancer and is receiving morphine for
pain management. Which of the following findings is the nurse's priority?: Res-
piratory rate 10/min
Using the airway, breathing, circulation approach to client care, the nurse should identify that a respiratory rate of
10/min is the priority finding. A respiratory rate of 10/min is an indication of opioid toxicity. The nurse should withhold
the next dose of the medication and notify the provider immediately.
4. A nurse is assessing four clients. Which of the following clients should the
nurse assess first?
A. A client who has COPD and a respiratory rate of 23/min
1/2
