ATI Priority setting frameworks advanced test TC

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