ATI priority setting frameworks advanced
test UPDATED Exam Questions and
CORRECT Answers
A public health nurse is triaging clients at the site of an explosion. The client with which of the
following injuries should be the nurses priority concern?
Facial abrasions
Penetrating head wound
Incomplete amputation of the foot
Tibia fracture requiring open reduction - CORRECT ANSWER - Incomplete amputation
of the foot
Survival is number one
Facial abrasion and fracture are delayed triage
Penetrating wound is minimal triage because survival is unlikely
A nurse is caring for a client who has a flaccid bladder following a spinal injury. Which of the
following actions should the nurse take first?
Initiate bladder training schedule
Administer solifenancin (Vesicare)
Insert an indwelling urinary cath
Perform intermittent catheterization - CORRECT ANSWER - Initiate a bladder training
schedule
Priority because it's least restrictive least invasive
A nurse is collecting data on a client who has a diagnoses of myasthenia gravies. Which of the
following complication is it most important for the nurse to monitor?
Diplopia-double vision
, Loss of bladder control
Paresthesias-tingling sensation in extremities or skin
Decreased respiratory effort - CORRECT ANSWER - Decreased respiratory effort
A nurse is caring for a client who was admitted to the unit 3 hr ago following a total hip
arthroplasty. Which of the following findings should be nurses priority concern?
Urinary output of 75 ml over past 3 hours
8 point elevation in pre surgery diastolic BP
Oxygen sat of 90% on oxygen at 2 L nasal cannula
Core body temp of 36.2 or 97.2 F - CORRECT ANSWER - Oxygen saturation of 90% on
oxygen at 2 L per nasal cannula
A nurse is caring for a client who has a compound fracture of the tibia and fibula and is in skin
traction. The client reports pain of 6 on a scale of 0 to 10 under the traction bandage. Which of
the following actions should the nurse take first?
Administer analgesic
Assist the client to shift positions
Check pedal pulse
Distract the client with music therapy - CORRECT ANSWER - Check pedal pulse
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 client 48 hour following abdominal surgery with redness and swelling at the edges of incision
A client following knee replacement surgery complaining of pain and warmth in the calf
A client admitted with cholecystitis who reports frequent nausea and vomiting
A client admitted with a GI bleed receiving packs RBCs for hemoglobin of 7.8 - CORRECT
ANSWER - A client following knee replacement surgery complaining of pain and warmth
in the calf
A nurse is caring for a client who is newly diagnosed with bipolar disorder and is currently
experiencing an acute mani episode. Which of the following is the priority concern of the nurse?
test UPDATED Exam Questions and
CORRECT Answers
A public health nurse is triaging clients at the site of an explosion. The client with which of the
following injuries should be the nurses priority concern?
Facial abrasions
Penetrating head wound
Incomplete amputation of the foot
Tibia fracture requiring open reduction - CORRECT ANSWER - Incomplete amputation
of the foot
Survival is number one
Facial abrasion and fracture are delayed triage
Penetrating wound is minimal triage because survival is unlikely
A nurse is caring for a client who has a flaccid bladder following a spinal injury. Which of the
following actions should the nurse take first?
Initiate bladder training schedule
Administer solifenancin (Vesicare)
Insert an indwelling urinary cath
Perform intermittent catheterization - CORRECT ANSWER - Initiate a bladder training
schedule
Priority because it's least restrictive least invasive
A nurse is collecting data on a client who has a diagnoses of myasthenia gravies. Which of the
following complication is it most important for the nurse to monitor?
Diplopia-double vision
, Loss of bladder control
Paresthesias-tingling sensation in extremities or skin
Decreased respiratory effort - CORRECT ANSWER - Decreased respiratory effort
A nurse is caring for a client who was admitted to the unit 3 hr ago following a total hip
arthroplasty. Which of the following findings should be nurses priority concern?
Urinary output of 75 ml over past 3 hours
8 point elevation in pre surgery diastolic BP
Oxygen sat of 90% on oxygen at 2 L nasal cannula
Core body temp of 36.2 or 97.2 F - CORRECT ANSWER - Oxygen saturation of 90% on
oxygen at 2 L per nasal cannula
A nurse is caring for a client who has a compound fracture of the tibia and fibula and is in skin
traction. The client reports pain of 6 on a scale of 0 to 10 under the traction bandage. Which of
the following actions should the nurse take first?
Administer analgesic
Assist the client to shift positions
Check pedal pulse
Distract the client with music therapy - CORRECT ANSWER - Check pedal pulse
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 client 48 hour following abdominal surgery with redness and swelling at the edges of incision
A client following knee replacement surgery complaining of pain and warmth in the calf
A client admitted with cholecystitis who reports frequent nausea and vomiting
A client admitted with a GI bleed receiving packs RBCs for hemoglobin of 7.8 - CORRECT
ANSWER - A client following knee replacement surgery complaining of pain and warmth
in the calf
A nurse is caring for a client who is newly diagnosed with bipolar disorder and is currently
experiencing an acute mani episode. Which of the following is the priority concern of the nurse?
