ATI - Priority-Setting Frameworks
Assessment 2.0 Exam Questions and
Answers 100% Pass
A nurse is assisting with client triage at the scene of a mass casualty event. Which
of the following clients should the nurse recommend for transport first?
-A client who reports a possible sprained wrist and is walking around.
-A client who has an open forearm fracture without visible drainage.
-A client who has a respiratory rate of 6/min and no pupil response.
-A client who has an abdominal wound that is actively bleeding. - ANSWER--A
client who has an abdominal wound that is actively bleeding.
A client who has an abdominal wound that is actively bleeding requires immediate
intervention for survival; therefore, when using the survival approach to client
care, the nurse should recommend this client for first transport to a health care
facility. A client who is hemorrhaging has an immediate threat to life.
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,Not A, as a client who reports a possible sprained wrist and is walking around does
not have an immediate threat to life and can wait for treatment; therefore, there is
another client the nurse should recommend for transport first.
Not B, as a client who has an open forearm fracture without visible drainage does
not have an immediate threat to life and can wait for treatment; therefore, there is
another client the nurse should recommend for transport first.
Not C, as a client who has a respiratory rate of 6/min and no pupil response has a
minimal chance of survival even with intervention; therefore, there is another
client the nurse should recommend for transport first.
A nurse is admitting a client who has hypertension. Using the nursing process,
which of the following actions should the nurse take first?
-Develop nursing diagnoses
-Perform a physical assessment
-Administer prescribed medications
-Develop goals and outcomes - ANSWER--Perform a physical assessment
The first action the nurse should take when using the nursing process is to assess
the client. Assessment of the client includes a physical examination, client
interview, review of the medical records, and general observation. A registered
nurse uses a five-step sequential nursing process, which includes assessment,
analysis, planning, implementation, and evaluation.
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, Not A, as the nurse should develop nursing diagnoses to guide nursing care
interventions; however, there is another action the nurse should take first.
Developing a nursing diagnosis, or analysis, is the second step of the nursing
process.
Not C, as the nurse should administer prescribed medications to treat the client's
condition; however, there is another action the nurse should take first. Performing
nursing interventions is the fourth step in the nursing process.
Not D, as the nurse should develop goals and outcomes to manage the client's
needs; however, there is another action the nurse should take first. Developing
goals and outcomes is the third step in the nursing process.
A nurse is caring for a client who reports feeling inferior and states that they are
not good enough. The nurse should recognize that these feelings fall under which
of the following categories of Maslow's Hierarchy of Needs?
-Love and belonging
-Self-actualization
-Safety
-Self-esteem - ANSWER--Self-esteem
COPYRIGHT 2025 ALL RIGHTS RESERVED, TRUSTED AND VERIFIED 3
Assessment 2.0 Exam Questions and
Answers 100% Pass
A nurse is assisting with client triage at the scene of a mass casualty event. Which
of the following clients should the nurse recommend for transport first?
-A client who reports a possible sprained wrist and is walking around.
-A client who has an open forearm fracture without visible drainage.
-A client who has a respiratory rate of 6/min and no pupil response.
-A client who has an abdominal wound that is actively bleeding. - ANSWER--A
client who has an abdominal wound that is actively bleeding.
A client who has an abdominal wound that is actively bleeding requires immediate
intervention for survival; therefore, when using the survival approach to client
care, the nurse should recommend this client for first transport to a health care
facility. A client who is hemorrhaging has an immediate threat to life.
COPYRIGHT 2025 ALL RIGHTS RESERVED, TRUSTED AND VERIFIED 1
,Not A, as a client who reports a possible sprained wrist and is walking around does
not have an immediate threat to life and can wait for treatment; therefore, there is
another client the nurse should recommend for transport first.
Not B, as a client who has an open forearm fracture without visible drainage does
not have an immediate threat to life and can wait for treatment; therefore, there is
another client the nurse should recommend for transport first.
Not C, as a client who has a respiratory rate of 6/min and no pupil response has a
minimal chance of survival even with intervention; therefore, there is another
client the nurse should recommend for transport first.
A nurse is admitting a client who has hypertension. Using the nursing process,
which of the following actions should the nurse take first?
-Develop nursing diagnoses
-Perform a physical assessment
-Administer prescribed medications
-Develop goals and outcomes - ANSWER--Perform a physical assessment
The first action the nurse should take when using the nursing process is to assess
the client. Assessment of the client includes a physical examination, client
interview, review of the medical records, and general observation. A registered
nurse uses a five-step sequential nursing process, which includes assessment,
analysis, planning, implementation, and evaluation.
COPYRIGHT 2025 ALL RIGHTS RESERVED, TRUSTED AND VERIFIED 2
, Not A, as the nurse should develop nursing diagnoses to guide nursing care
interventions; however, there is another action the nurse should take first.
Developing a nursing diagnosis, or analysis, is the second step of the nursing
process.
Not C, as the nurse should administer prescribed medications to treat the client's
condition; however, there is another action the nurse should take first. Performing
nursing interventions is the fourth step in the nursing process.
Not D, as the nurse should develop goals and outcomes to manage the client's
needs; however, there is another action the nurse should take first. Developing
goals and outcomes is the third step in the nursing process.
A nurse is caring for a client who reports feeling inferior and states that they are
not good enough. The nurse should recognize that these feelings fall under which
of the following categories of Maslow's Hierarchy of Needs?
-Love and belonging
-Self-actualization
-Safety
-Self-esteem - ANSWER--Self-esteem
COPYRIGHT 2025 ALL RIGHTS RESERVED, TRUSTED AND VERIFIED 3
