Priority Setting Frameworks (Beginner Test)

A nurse is collecting data on four clients. Which of following is the highest priority finding by the nurse? - Diarrhea Rationale: 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? - A client who had abdominal surgery 10 days ago and reports feeling his incision pop Rationale: 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 nurse is 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? - Creating meaningful social relationships A nurse is preparing to administer oral medications to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse? - Have the client position the head with the chin down while swallowing. A nurse is conducting therapeutic medication monitoring on four clients. Which of the following findings should be immediately reported to the provider? Options: Magnesium sulfate 4 mEq/L Peak serum gentamicin 6 mcg/mL Lithium carbonate 0.8 mEq/L Digoxin 3.0 ng/mL - Digoxin 3.0 ng/mL