ATI Priority setting frameworks advanced
test TC
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 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 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 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
Before you can formulate a plan of action, implement a nursing intervention, or notify a
provider of a change in the client's condition, you must first collect adequate data from
the client so a plan of care can be developed. 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 is experiencing panic level anxiety. Which of the
following actions should the nurse take first?
Engage the client in physical activity
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 restraints. Physical or chemical restraints should only be
used when the safety of the client, staff, or others is at risk. 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.
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
ABC priority setting framework, which emphasizes the basic core of human functioning -
having an open airway, being able to breathe in adequate amounts of oxygen, and
circulating oxygen to the body's organs via the blood. An alteration in any of these can
indicate a threat to life, and is therefore, the nurse's priority concern. 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.
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
When applying Maslow's Hierarchy of Needs priority setting framework, physiological
needs take precedence and should be reviewed first. Client needs should then be
addressed by following the remaining four hierarchal levels. It is important, however, to
consider all contributing client factors, as higher levels of the pyramid can compete with
those at the lower levels, depending on the specific client situation. 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 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
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.
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
test TC
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 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 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 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
Before you can formulate a plan of action, implement a nursing intervention, or notify a
provider of a change in the client's condition, you must first collect adequate data from
the client so a plan of care can be developed. 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 is experiencing panic level anxiety. Which of the
following actions should the nurse take first?
Engage the client in physical activity
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 restraints. Physical or chemical restraints should only be
used when the safety of the client, staff, or others is at risk. 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.
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
ABC priority setting framework, which emphasizes the basic core of human functioning -
having an open airway, being able to breathe in adequate amounts of oxygen, and
circulating oxygen to the body's organs via the blood. An alteration in any of these can
indicate a threat to life, and is therefore, the nurse's priority concern. 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.
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
When applying Maslow's Hierarchy of Needs priority setting framework, physiological
needs take precedence and should be reviewed first. Client needs should then be
addressed by following the remaining four hierarchal levels. It is important, however, to
consider all contributing client factors, as higher levels of the pyramid can compete with
those at the lower levels, depending on the specific client situation. 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 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
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.
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
