ATI Video Case Study: Priority Setting
A nurse is preparing to apply a condom catheter to a male client. Which of the following
actions should the nurse take after performing hand hygiene and applying clean gloves?
- Answer Check the condition of the penile shaft.
*The first action the nurse should take when using the nursing process is assessment.
To maintain safety and prevent injury to the client by taking the necessary precautions,
the nurse should check the condition of the client's skin to determine a baseline. The
nurse should then monitor the client's skin for redness, swelling, or lesions.
A nurse enters a client's room and sees the client lying on the floor next to the bed.
Which of the following actions should the nurse take first? - Answer Obtain the client's
vital signs.
*The greatest risk to this client is injury from falling out of bed; therefore, the first action
for the nurse to take is to obtain the client's vital signs to verify that the client is stable.
A nurse is assessing four clients. Which of the following clients should the nurse assess
first? - Answer A client who has a chest tube and has asymmetrical chest movement
*When using the acute versus chronic approach to client care, the nurse should place
the priority on the client who has a chest tube and has asymmetrical chest movement
because this can indicate a tension pneumothorax.
A nurse is assessing a client who has cancer and is receiving morphine for pain
management. Which of the following findings is the nurse's priority? - Answer
Respiratory rate 10/min
*The nurse should identify that the respiratory rate of 10/min is the priority finding by
using the airway, breathing, circulation approach to client care. A respiratory rate of
10/min is an indication of toxicity. The nurse should not administer the next dose of
medication and should notify the provider immediately.
A nurse is the PACU is caring for a client who is postoperative following an abdominal
hysterectomy. Which of the following actions should the nurse take first? - Answer Place
the client in a side-lying position.
*The greatest risk to this client is injury from an obstructed airway; therefore, the first
action the nurse should take is to place the client in a side-lying position to allow her
tongue to fall to the side of her mouth, instead of having her tongue obstruct her airway.
A nurse is preparing to apply a condom catheter to a male client. Which of the following
actions should the nurse take after performing hand hygiene and applying clean gloves?
- Answer Check the condition of the penile shaft.
*The first action the nurse should take when using the nursing process is assessment.
To maintain safety and prevent injury to the client by taking the necessary precautions,
the nurse should check the condition of the client's skin to determine a baseline. The
nurse should then monitor the client's skin for redness, swelling, or lesions.
A nurse enters a client's room and sees the client lying on the floor next to the bed.
Which of the following actions should the nurse take first? - Answer Obtain the client's
vital signs.
*The greatest risk to this client is injury from falling out of bed; therefore, the first action
for the nurse to take is to obtain the client's vital signs to verify that the client is stable.
A nurse is assessing four clients. Which of the following clients should the nurse assess
first? - Answer A client who has a chest tube and has asymmetrical chest movement
*When using the acute versus chronic approach to client care, the nurse should place
the priority on the client who has a chest tube and has asymmetrical chest movement
because this can indicate a tension pneumothorax.
A nurse is assessing a client who has cancer and is receiving morphine for pain
management. Which of the following findings is the nurse's priority? - Answer
Respiratory rate 10/min
*The nurse should identify that the respiratory rate of 10/min is the priority finding by
using the airway, breathing, circulation approach to client care. A respiratory rate of
10/min is an indication of toxicity. The nurse should not administer the next dose of
medication and should notify the provider immediately.
A nurse is the PACU is caring for a client who is postoperative following an abdominal
hysterectomy. Which of the following actions should the nurse take first? - Answer Place
the client in a side-lying position.
*The greatest risk to this client is injury from an obstructed airway; therefore, the first
action the nurse should take is to place the client in a side-lying position to allow her
tongue to fall to the side of her mouth, instead of having her tongue obstruct her airway.
