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
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
