Priority Setting Frameworks Advanced
Test | Comprehensive Questions with
Answers & Rationales
1. 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 a priority concern
of the nurse?
A) Enhancing self-esteem
B) Preventing injury
C) Encouraging problem solving
D) Promoting usefulness
Correct Answer: B
Rationale: During an acute manic episode, clients may
engage in impulsive, reckless behaviors that can lead to
injury. Safety is the priority concern. Maslow's hierarchy
places safety as a basic need that must be addressed
before higher-level needs such as self-esteem and problem-
solving.
2. 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) A client 48 hr following abdominal surgery with redness
and swelling at the edges of the incision
,B) A client following knee replacement surgery complaining
of pain and warmth in the calf
C) A client admitted with cholecystitis who reports frequent
nausea and vomiting
D) A client admitted with a GI bleed receiving packed RBCs
for hemoglobin of 7.8 gm/dL
Correct Answer: B
Rationale: Pain and warmth in the calf following knee
replacement surgery may indicate deep vein thrombosis
(DVT), which can lead to pulmonary embolism. This is a life-
threatening emergency requiring immediate evaluation. The
other clients have important but less urgent concerns.
3. 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?
A) Evaluate level of consciousness
B) Place the client on bed rest
C) Encourage increased fluid intake
D) Initiate continuous ECG monitoring
Correct Answer: A
Rationale: Tachypnea (respiratory rate of 26/min) may
indicate hypoxia or respiratory distress. Evaluating the
client's level of consciousness is the first step to assess
oxygenation status. Changes in LOC can be an early sign of
hypoxia. The ABCs prioritize assessment of airway,
breathing, and circulation.
,4. 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?
A) Place proper lights and reflectors on the bicycle
B) Use a properly-fitted bicycle helmet
C) Wear light-colored clothing at night
D) Use hand signals when turning
Correct Answer: B
Rationale: A properly-fitted bicycle helmet is the most
important safety measure to prevent head injuries, which
are the leading cause of bicycle-related deaths. While the
other options are important safety practices, helmet use is
the priority for injury prevention.
5. A nurse is caring for a client who was admitted to the unit
three hours ago following a total hip arthroplasty. Which of
the following findings should be the nurse's priority
concern?
A) Urinary output of 75 mL over the past 3 hr
B) 8-point elevation in the pre-surgery diastolic blood
pressure
C) Oxygen saturation of 90% on oxygen at 2 L per nasal
cannula
D) Core body temperature of 36.2°C (97.2°F)
, Correct Answer: C
Rationale: An oxygen saturation of 90% on oxygen indicates
hypoxemia and is the priority concern. This follows the
ABCs (Airway, Breathing, Circulation). Hypoxemia can lead
to tissue damage and requires immediate intervention. The
other findings are important but not as urgent.
6. A nurse is caring for a client who is experiencing panic-
level anxiety. Which of the following actions should the
nurse take first?
A) Administer an anti-anxiety medication
B) Take the client to a place of seclusion
C) Obtain an order for soft wrist restraints
D) Engage the client in physical activity
Correct Answer: D
Rationale: Engaging the client in physical activity helps
channel the excess energy associated with panic-level
anxiety and can be calming. This is the least restrictive and
most appropriate first intervention. Seclusion and restraints
should only be used as a last resort.
7. 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?
A) Administer nebulized epinephrine (racemic epinephrine)
B) Ensure adequate hydration
Test | Comprehensive Questions with
Answers & Rationales
1. 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 a priority concern
of the nurse?
A) Enhancing self-esteem
B) Preventing injury
C) Encouraging problem solving
D) Promoting usefulness
Correct Answer: B
Rationale: During an acute manic episode, clients may
engage in impulsive, reckless behaviors that can lead to
injury. Safety is the priority concern. Maslow's hierarchy
places safety as a basic need that must be addressed
before higher-level needs such as self-esteem and problem-
solving.
2. 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) A client 48 hr following abdominal surgery with redness
and swelling at the edges of the incision
,B) A client following knee replacement surgery complaining
of pain and warmth in the calf
C) A client admitted with cholecystitis who reports frequent
nausea and vomiting
D) A client admitted with a GI bleed receiving packed RBCs
for hemoglobin of 7.8 gm/dL
Correct Answer: B
Rationale: Pain and warmth in the calf following knee
replacement surgery may indicate deep vein thrombosis
(DVT), which can lead to pulmonary embolism. This is a life-
threatening emergency requiring immediate evaluation. The
other clients have important but less urgent concerns.
3. 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?
A) Evaluate level of consciousness
B) Place the client on bed rest
C) Encourage increased fluid intake
D) Initiate continuous ECG monitoring
Correct Answer: A
Rationale: Tachypnea (respiratory rate of 26/min) may
indicate hypoxia or respiratory distress. Evaluating the
client's level of consciousness is the first step to assess
oxygenation status. Changes in LOC can be an early sign of
hypoxia. The ABCs prioritize assessment of airway,
breathing, and circulation.
,4. 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?
A) Place proper lights and reflectors on the bicycle
B) Use a properly-fitted bicycle helmet
C) Wear light-colored clothing at night
D) Use hand signals when turning
Correct Answer: B
Rationale: A properly-fitted bicycle helmet is the most
important safety measure to prevent head injuries, which
are the leading cause of bicycle-related deaths. While the
other options are important safety practices, helmet use is
the priority for injury prevention.
5. A nurse is caring for a client who was admitted to the unit
three hours ago following a total hip arthroplasty. Which of
the following findings should be the nurse's priority
concern?
A) Urinary output of 75 mL over the past 3 hr
B) 8-point elevation in the pre-surgery diastolic blood
pressure
C) Oxygen saturation of 90% on oxygen at 2 L per nasal
cannula
D) Core body temperature of 36.2°C (97.2°F)
, Correct Answer: C
Rationale: An oxygen saturation of 90% on oxygen indicates
hypoxemia and is the priority concern. This follows the
ABCs (Airway, Breathing, Circulation). Hypoxemia can lead
to tissue damage and requires immediate intervention. The
other findings are important but not as urgent.
6. A nurse is caring for a client who is experiencing panic-
level anxiety. Which of the following actions should the
nurse take first?
A) Administer an anti-anxiety medication
B) Take the client to a place of seclusion
C) Obtain an order for soft wrist restraints
D) Engage the client in physical activity
Correct Answer: D
Rationale: Engaging the client in physical activity helps
channel the excess energy associated with panic-level
anxiety and can be calming. This is the least restrictive and
most appropriate first intervention. Seclusion and restraints
should only be used as a last resort.
7. 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?
A) Administer nebulized epinephrine (racemic epinephrine)
B) Ensure adequate hydration
