ATI - Priority Setting Framework (Beginning Test)

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 include in the instructions? A) Place the infant in a supine position when sleeping B) place the infant on a firm mattress when sleeping C) avoid covering the infant with loose bedding while sleeping D) avoid leaving stuffed animals in the crib with the sleeping infant A) Place the infant in a supine position when sleeping Framework: safety and risk reduction This intervention has had the greatest impact on reducing the occurrence of SIDS. A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first? A) Obtain an ECG. B) Administer oral potassium C) Encourage potassium-rich foods D) Monitor I & O A) Obtain an ECG Framework: Maslows Hierarchy of needs Obtaining an ECG will assist in determining the presence of dysrhythmias related to a serum potassium level below the expected reference range. A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first? A) Place O2 at 2 L per nasal canula on the client B) Place the client in the orthopneic position C) Perform chest percussion D) perform nasotracheal suction B) Place the client in the orthopneic position Framework: least restrictive, least invasive Placing the client in the orthopneic position allows for maximum chest expansion, which improves respiratory effort. A nurse is collecting data on four clients. Which of the following findings is the most urgent? A) bladder distension and urgency B) pedal edema C) warmth and pain in the calf D) hypoactive bowel sounds C) Warmth and pain in the calf