Priority-Setting Frameworks

A nurse is assessing a client using the ABCDE priority-setting approach. Which of the following actions should the nurse take when completing the exposure component of this priority setting method? (Select all that apply.) - Answer- Observe the client's lower extremities for indications of deep vein thrombosis. Measure the client's temperature. Check the client for bruising. A nurse has received change-of-shift report on four clients. Which of the following clients should the nurse plan to see first? - Answer- A client who has audible wheezing during respirations A nurse is prioritizing care for a client. Identify the priority order of client needs using Maslow's Hierarchy of Needs. (Move the levels into the box on the right, placing them in the order of priority. Use all the levels.) - Answer- Physiological Safety Love/Belonging Esteem Self-actualization A nurse is caring for a client who is experiencing unexpected manifestations with several body systems. Which of the following priority setting frameworks should the nurse use to prioritize client assessment? - Answer- ABCDE A nurse is performing an admission assessment on a client. Using the safety and risk reduction priority setting framework, which of the following findings should the nurse identify as the priority? - Answer- The client reports dizziness when standing A nurse is caring for a client who reports new onset of abdominal pain. The nurse should assign the client's condition to which of the following categories when prioritizing care? - Answer- Urgent A nurse is assisting with client triage at the scene of a mass casualty event. Which of the following clients should the nurse recommend for transport first? - Answer- A client who has an abdominal wound that is actively bleeding A nurse is reviewing the medical records of four clients. Which of the following clients should the nurse identify as the priority for care? - Answer- A client who received digoxin and has a heart rate of 48/min A nurse is admitting a client who has hypertension. Using the nursing process, which of the following actions should the nurse take first? - Answer- Perform a physical assessment