ATI - Priority Setting Frameworks
Beginning Test Questions And All
Verified Answers.
A nurse is collecting data on four clients. Which of the following is the highest priority finding by the
nurse? - Answer Diarrhea
Answering this item requires application of the 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 the highest priority because the airway must be open and clear for oxygen
exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because
adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third
highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only
occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC
priority setting framework, maintaining circulation is the nurse's priority concern. Diarrhea can deplete
the body of fluids and cause a decrease in the circulating blood volume. Based on this knowledge and
using the ABC priority setting framework, this is the highest priority finding by the nurse
A nurse in a rehabilitation facility has received report on four clients. Which of the following should the
nurse evaluate first? - Answer A client who had abdominal surgery 10 days ago and reports feeling his
incision pop
Answering this item requires application of the acute versus chronic priority setting framework. Using
this framework, acute needs are typically the priority need because they pose more of a threat to the
client. Because chronic needs usually develop over a period of time, the client has more of an
opportunity to adapt to the alteration in health. It is also important to attend to alterations when they
are in the acute phase so they don't escalate into a life-threatening event or evolve into a chronic
alteration in health. Wound dehiscence or evisceration most commonly occurs 3 to 11 days following
surgery and can be caused by not splinting the surgical site when moving, forceful coughing, vomiting, or
straining. Clients often report feeling the incision "pop," indicating either dehiscence or evisceration has
occurred. Based on the acute versus chronic priority setting framework, the nurse should evaluate this
client first.
, 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? - Answer Creating meaningful social relationships
Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of
priority. The first level consists of physiological needs; the second level consists of safety and security
needs; the third level consists of love and belonging needs; the fourth level consists of personal
achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability
to problem solve and cope with life situations. 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 third level of Maslow's Hierarchy of Needs
includes love, affection, and social relationships in fulfilling love and belonging needs. Social relationships
are a component of friendship, which would be included in the third level of Maslow's Hierarchy of
Needs. Based on Maslow's Hierarchy of Needs, this is the client's priority need.
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? -
Answer Have the client position the head with the chin down while swallowing
Answering this item requires application of the safety and risk reduction priority setting framework. This
framework assigns priority to the factor or situation posing the greatest safety risk to the client. When
there are several risks to client safety, the one posing the greatest threat is the highest priority. It might
be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing
knowledge to identify which risk poses the greatest threat to the client. 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. Based on the safety and risk reduction priority setting framework, this should be the nurse's
priority action. Preventing aspiration is further supported as the priority by the ABC priority setting
framework.
A nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be
immediately reported to the provider? - Answer Digoxin 3.0ng/mL
Answering this item requires application of the unstable versus stable priority setting framework. Using
this framework, unstable clients get priority because of needs that threaten their survival. Threats or
problems involving the airway, breathing, or circulatory status are considered life-threatening needs that
should be addressed first. Clients whose vital signs or laboratory values indicate a risk for becoming
unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed
to determine which option poses the greatest risk to the client. This digoxin level is above the expected
Beginning Test Questions And All
Verified Answers.
A nurse is collecting data on four clients. Which of the following is the highest priority finding by the
nurse? - Answer Diarrhea
Answering this item requires application of the 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 the highest priority because the airway must be open and clear for oxygen
exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because
adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third
highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only
occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the ABC
priority setting framework, maintaining circulation is the nurse's priority concern. Diarrhea can deplete
the body of fluids and cause a decrease in the circulating blood volume. Based on this knowledge and
using the ABC priority setting framework, this is the highest priority finding by the nurse
A nurse in a rehabilitation facility has received report on four clients. Which of the following should the
nurse evaluate first? - Answer A client who had abdominal surgery 10 days ago and reports feeling his
incision pop
Answering this item requires application of the acute versus chronic priority setting framework. Using
this framework, acute needs are typically the priority need because they pose more of a threat to the
client. Because chronic needs usually develop over a period of time, the client has more of an
opportunity to adapt to the alteration in health. It is also important to attend to alterations when they
are in the acute phase so they don't escalate into a life-threatening event or evolve into a chronic
alteration in health. Wound dehiscence or evisceration most commonly occurs 3 to 11 days following
surgery and can be caused by not splinting the surgical site when moving, forceful coughing, vomiting, or
straining. Clients often report feeling the incision "pop," indicating either dehiscence or evisceration has
occurred. Based on the acute versus chronic priority setting framework, the nurse should evaluate this
client first.
, 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? - Answer Creating meaningful social relationships
Answering this item requires consideration of Maslow's Hierarchy of Needs, which includes five levels of
priority. The first level consists of physiological needs; the second level consists of safety and security
needs; the third level consists of love and belonging needs; the fourth level consists of personal
achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability
to problem solve and cope with life situations. 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 third level of Maslow's Hierarchy of Needs
includes love, affection, and social relationships in fulfilling love and belonging needs. Social relationships
are a component of friendship, which would be included in the third level of Maslow's Hierarchy of
Needs. Based on Maslow's Hierarchy of Needs, this is the client's priority need.
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? -
Answer Have the client position the head with the chin down while swallowing
Answering this item requires application of the safety and risk reduction priority setting framework. This
framework assigns priority to the factor or situation posing the greatest safety risk to the client. When
there are several risks to client safety, the one posing the greatest threat is the highest priority. It might
be necessary to use Maslow's Hierarchy of Needs, the ABC priority setting framework, or nursing
knowledge to identify which risk poses the greatest threat to the client. 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. Based on the safety and risk reduction priority setting framework, this should be the nurse's
priority action. Preventing aspiration is further supported as the priority by the ABC priority setting
framework.
A nurse is conducting therapeutic medication monitoring on four clients. Which of the findings should be
immediately reported to the provider? - Answer Digoxin 3.0ng/mL
Answering this item requires application of the unstable versus stable priority setting framework. Using
this framework, unstable clients get priority because of needs that threaten their survival. Threats or
problems involving the airway, breathing, or circulatory status are considered life-threatening needs that
should be addressed first. Clients whose vital signs or laboratory values indicate a risk for becoming
unstable are also a higher priority than clients who are stable. Nursing knowledge might also be needed
to determine which option poses the greatest risk to the client. This digoxin level is above the expected
