ATI: Priority Setting Frameworks Beginner Test
Questions and Answers with Rationale
1. A nurse is collecting data on four clients. Which of following is the highest priority finding by the
nurse?
{{ANS}}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.)
2.A nurse in a rehabilitation facility has received report on four clients. Which of the following should the
nurse evaluate first?
{{ANS}}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.)
3.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?
{{ANS}}Creating meaningful social relationships)
4.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?
{{ANS}}Have the client position the head with the chin down while swallowing.)
5.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
Questions and Answers with Rationale
1. A nurse is collecting data on four clients. Which of following is the highest priority finding by the
nurse?
{{ANS}}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.)
2.A nurse in a rehabilitation facility has received report on four clients. Which of the following should the
nurse evaluate first?
{{ANS}}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.)
3.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?
{{ANS}}Creating meaningful social relationships)
4.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?
{{ANS}}Have the client position the head with the chin down while swallowing.)
5.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
