ATI - Priority Setting Framework (Beginning Test)
A nurse is collecting data on four clients. Which of the following is the highest
priority finding by the nurse?
A) Malaise
B) Anorexia
C) Headache
D) Diarrhea
D) Diarrhea
Framework: ABCs
Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood
volume.
A nurse in a rehabilitation facility has received report on four clients. Which of the
following should the nurse evaluate first?
A) A client who has peripheral vascular disease and reports numbness in the toes
B) client who has depression & is easily distracted
C) A client who has Alzheimer's disease and is unable to complete ADLS
D) A client who had abdominal surgery 10 days ago and reports feeling his
incision pop
D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop
Framework: acute vs. chronic
Clients often report feeling the incision pop, indicating either dehiscence or evisceration
has occurred.
A nurses 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?
A) establishing a sense of achievement
B) contributing to society
C) creating meaningful social relationships
D) enhancing self- confidence
C) Creating meaningful social relationships
Framework:
Maslows Hierarchy of needs
Social relationships are a component of friendship, which would be included in the 3rd
level.
A nurse is preparing to administer oral medication to a client who has unilateral
weakness following a cerebrovascular accident (CVA). Which of the following
should be the priority action of the nurse?
, A) Administer medications w/ meals when possible
B) Ensure client understanding of medication's effects
C) Determine the client's ability to self-administer meds
D) have the client position the head w/ chin down while swallowing
D) Have the client position the head with the chin down while swallowing
Framework: safety and risk reduction
Clients are at risk for aspiration following a CVA, and having the client position the head
with the chin down while swallowing reduces this risk.
A nurse is conducting therapeutic medication monitoring on four clients. Which
of the findings should be immediately reported to the provider?
A) Lithium carbonate 0.8 mmol/L
B) Digoxin 3.0 ng/mL
C) Peak serum gentamicin 6 mcg/mL
D) Magnesium sulfate 4 mEq/L
B) Digoxin 3.0 ng/mL
Framework: unstable vs. stable
This digoxin level is above the expected reference range and indicates digoxin toxicity
The therapeutic range for lithium has been established at 0.6 - 1.2 mmol/L.
Therapeutic serum digoxin levels range from 0.5-2 ng/mL.
Conventional dosing of gentamicin: Peak: 4-10 mcg/ml.
Magnesium sulfate therapeutic level of 3.5 to 7 mEq/L.
A nurses caring for a client who has a urinary track infection. The client is
disoriented and found wandering on another unit. Which of the following actions
should the nurse take first?
A) Ensure all 4 side rails are up.
B) Administer a prescribed sedative.
C) Place the client in soft wrist restraints
D) Move the client to a room near the nurses' station
D) Move the client to room near the nurses station
Framework: least restrictive, least invasive
Moving the client to a room near the nurses station allows for more frequent observation
and promotes client safety.
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
A nurse is collecting data on four clients. Which of the following is the highest
priority finding by the nurse?
A) Malaise
B) Anorexia
C) Headache
D) Diarrhea
D) Diarrhea
Framework: ABCs
Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood
volume.
A nurse in a rehabilitation facility has received report on four clients. Which of the
following should the nurse evaluate first?
A) A client who has peripheral vascular disease and reports numbness in the toes
B) client who has depression & is easily distracted
C) A client who has Alzheimer's disease and is unable to complete ADLS
D) A client who had abdominal surgery 10 days ago and reports feeling his
incision pop
D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop
Framework: acute vs. chronic
Clients often report feeling the incision pop, indicating either dehiscence or evisceration
has occurred.
A nurses 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?
A) establishing a sense of achievement
B) contributing to society
C) creating meaningful social relationships
D) enhancing self- confidence
C) Creating meaningful social relationships
Framework:
Maslows Hierarchy of needs
Social relationships are a component of friendship, which would be included in the 3rd
level.
A nurse is preparing to administer oral medication to a client who has unilateral
weakness following a cerebrovascular accident (CVA). Which of the following
should be the priority action of the nurse?
, A) Administer medications w/ meals when possible
B) Ensure client understanding of medication's effects
C) Determine the client's ability to self-administer meds
D) have the client position the head w/ chin down while swallowing
D) Have the client position the head with the chin down while swallowing
Framework: safety and risk reduction
Clients are at risk for aspiration following a CVA, and having the client position the head
with the chin down while swallowing reduces this risk.
A nurse is conducting therapeutic medication monitoring on four clients. Which
of the findings should be immediately reported to the provider?
A) Lithium carbonate 0.8 mmol/L
B) Digoxin 3.0 ng/mL
C) Peak serum gentamicin 6 mcg/mL
D) Magnesium sulfate 4 mEq/L
B) Digoxin 3.0 ng/mL
Framework: unstable vs. stable
This digoxin level is above the expected reference range and indicates digoxin toxicity
The therapeutic range for lithium has been established at 0.6 - 1.2 mmol/L.
Therapeutic serum digoxin levels range from 0.5-2 ng/mL.
Conventional dosing of gentamicin: Peak: 4-10 mcg/ml.
Magnesium sulfate therapeutic level of 3.5 to 7 mEq/L.
A nurses caring for a client who has a urinary track infection. The client is
disoriented and found wandering on another unit. Which of the following actions
should the nurse take first?
A) Ensure all 4 side rails are up.
B) Administer a prescribed sedative.
C) Place the client in soft wrist restraints
D) Move the client to a room near the nurses' station
D) Move the client to room near the nurses station
Framework: least restrictive, least invasive
Moving the client to a room near the nurses station allows for more frequent observation
and promotes client safety.
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
