ATI - Priority Setting Frameworks Beginning
Test, 302 Exam 1, NurseLogic 2.0 Nursing
Concepts Beginning Test, Assessment 302
Study Guide for exam 1
A nurse is collecting data on four clients. Which of the following is the highest
priority finding by the nurse?
Diarrhea
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
A nurses 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 medication 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 findings should be immediately reported to the provider?
Digoxin 3.0ng/mL
A nurses caring for a client who has a urinary track infection. The client is
disoriented and found wandering on another unit. Which of the following actions
should the nurse take first?
Move the client to room near the nurses station
A nurse is reinforcing discharge teaching to a new mother regarding sudden
infant death syndrome (SIDS). Which of the following is the highest priority to
include in the instructions?
Place the infant in a supine position when sleeping
A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L.
Which of the following actions should the nurse take first?
Obtain an ECG
A nurse is caring for a client who is having difficulty breathing. Which of the
following actions should the nurse take first?
Place the client in the orthopneic position
A nurse is collecting data on four clients. Which of the following findings is the
most urgent?
Warmth and pain in the calf
A nurse in an urgent care clinic is caring for a client who has bronchitis with thick
pulmonary secretions. The client's oxygen saturation level is 90% on room air.
Which of the following actions should the nurse take first?
Assist client to cough effectively
A nurse in a long-term care facility is assisting with the admission of several
clients. To prevent falls in hospitalized clients, which of the following actions
should the nurse take first?
,Determine the mobility status of each patient
A nurse is reviewing the lab results for four clients. The client with which of the
following values requires immediate intervention?
Platelets 95,000 mm3
A nurse working on the cardiac unit hears an alarm and finds one of the heart
monitor screens at the nurse's station is displaying a straight line, indicating a
client is in cardiac arrest. Which of the following actions should the nurse take
first?
Check on the client
A nurses caring for a client who is in the immediate post operative period
following a tracheotomy. Which of the following is the nurses priority action?
Maintaining a patent airway
A newly hired nurse is reviewing the facilities emergency preparedness plan.
Based on a review of the four triage categories, the nurse should provide power
you care to clients who are in which of the following categories during a
disaster?
Immediate
A nurse in a provider's office has collected data on four clients. Which of the
following clients should be the nurse's priority concern?
A client who is having a nosebleed associated with hypertension
A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the
following actions should the nurse take first when evaluating for fluid volume
deficit?
Check the heart rate and blood pressure
A nurse is assisting with the admission of a client who has decreased circulation
in the left leg. Which of the following is the first action the nurse should take?
Check the leg for warmth and edema
A nurse is caring for a newly admitted client. Which of the following client needs
should the nurse address first?
Hypoxic
ABC's of nursing
airway, breathing, circulation
Vital Sign Ranges
Blood pressure: 90/60 mm Hg to 120/80 mm Hg.
Breathing: 12 to 18 breaths per minute.
Pulse: 60 to 100 beats per minute.
Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)
Hypertension Stage 1
Systolic: 140-159
Diastolic: 90-99
Stages of hypertension
Normal BP: <120 systolic/<80 diastolic
Pre HTN: systolic 120-139/80-89 diastolic
Stage 1 HTN: systolic 140-159/ 90-99 diastolic
Stage 2 HTN: systolic >160/ >100 diastolic
vital signs lower with age
, Finger pads
pulses, texture, size, consistency, shape, crepitus, lymph nodes
Asian culture
Health is balance of yin and yang , treatment: herbal remedies , acupuncture , believe
pain must be endured silently
answer:opiods
What is the normal core temp when taken orally?
96 F - 99 F (or 36.5 C - 37.7 C)
What are older adults normal core temp?
95 F - 97.5 F
Normal pulse?
60-100 beats/minute
What are amplitude levels?
The strength of the pulse
What does 0 amplitude level mean?
pulse is absent
What does 1+ amplitude level mean?
Pulse is weak and can be obliterated easily
What does 2+ amplitude level mean?
Pulse is normal and can be obliterated with moderate pressure
What does 3+ amplitude level mean?
Pulse is bounding and cannot be obliterated without a lot of force
What is the apical site used for?
Taken for most accurate pulse/heart rate
What are normal pulse oximeter levels?
95% - 100%
What are some reasons a pulse ox reading can be lower?
Hypothermia, nail polish, decreased hemoglobin or patient is moving
What are normal amounts of respirations?
12-20 breaths/minute
What is a normal blood pressure?
120/80
What are Korotkoff's sounds?
Sounds you hear when taking someone's blood pressure
Explain each phase of Korotkoff's sounds?
Phase 1: repettive tapping; first tapping indicated systolic pressure
Phase 2: muffled/swishing sounds; can be present if patient is hypertensive
Phase 3: crisp and loud sounds indicating blood is rushing back
Phase 4: blowing sounds until all sounds disappear
Phase 5: last sound heard is the diastolic measurement
What is pulse pressure?
The difference between systolic and diastolic measurements
What does ADPIE stand for?
Assessment, diagnosis, planning, implementation, evaluation
What do you do in the assessment phase?
Collect subjective and objective data
Test, 302 Exam 1, NurseLogic 2.0 Nursing
Concepts Beginning Test, Assessment 302
Study Guide for exam 1
A nurse is collecting data on four clients. Which of the following is the highest
priority finding by the nurse?
Diarrhea
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
A nurses 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 medication 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 findings should be immediately reported to the provider?
Digoxin 3.0ng/mL
A nurses caring for a client who has a urinary track infection. The client is
disoriented and found wandering on another unit. Which of the following actions
should the nurse take first?
Move the client to room near the nurses station
A nurse is reinforcing discharge teaching to a new mother regarding sudden
infant death syndrome (SIDS). Which of the following is the highest priority to
include in the instructions?
Place the infant in a supine position when sleeping
A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L.
Which of the following actions should the nurse take first?
Obtain an ECG
A nurse is caring for a client who is having difficulty breathing. Which of the
following actions should the nurse take first?
Place the client in the orthopneic position
A nurse is collecting data on four clients. Which of the following findings is the
most urgent?
Warmth and pain in the calf
A nurse in an urgent care clinic is caring for a client who has bronchitis with thick
pulmonary secretions. The client's oxygen saturation level is 90% on room air.
Which of the following actions should the nurse take first?
Assist client to cough effectively
A nurse in a long-term care facility is assisting with the admission of several
clients. To prevent falls in hospitalized clients, which of the following actions
should the nurse take first?
,Determine the mobility status of each patient
A nurse is reviewing the lab results for four clients. The client with which of the
following values requires immediate intervention?
Platelets 95,000 mm3
A nurse working on the cardiac unit hears an alarm and finds one of the heart
monitor screens at the nurse's station is displaying a straight line, indicating a
client is in cardiac arrest. Which of the following actions should the nurse take
first?
Check on the client
A nurses caring for a client who is in the immediate post operative period
following a tracheotomy. Which of the following is the nurses priority action?
Maintaining a patent airway
A newly hired nurse is reviewing the facilities emergency preparedness plan.
Based on a review of the four triage categories, the nurse should provide power
you care to clients who are in which of the following categories during a
disaster?
Immediate
A nurse in a provider's office has collected data on four clients. Which of the
following clients should be the nurse's priority concern?
A client who is having a nosebleed associated with hypertension
A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the
following actions should the nurse take first when evaluating for fluid volume
deficit?
Check the heart rate and blood pressure
A nurse is assisting with the admission of a client who has decreased circulation
in the left leg. Which of the following is the first action the nurse should take?
Check the leg for warmth and edema
A nurse is caring for a newly admitted client. Which of the following client needs
should the nurse address first?
Hypoxic
ABC's of nursing
airway, breathing, circulation
Vital Sign Ranges
Blood pressure: 90/60 mm Hg to 120/80 mm Hg.
Breathing: 12 to 18 breaths per minute.
Pulse: 60 to 100 beats per minute.
Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)
Hypertension Stage 1
Systolic: 140-159
Diastolic: 90-99
Stages of hypertension
Normal BP: <120 systolic/<80 diastolic
Pre HTN: systolic 120-139/80-89 diastolic
Stage 1 HTN: systolic 140-159/ 90-99 diastolic
Stage 2 HTN: systolic >160/ >100 diastolic
vital signs lower with age
, Finger pads
pulses, texture, size, consistency, shape, crepitus, lymph nodes
Asian culture
Health is balance of yin and yang , treatment: herbal remedies , acupuncture , believe
pain must be endured silently
answer:opiods
What is the normal core temp when taken orally?
96 F - 99 F (or 36.5 C - 37.7 C)
What are older adults normal core temp?
95 F - 97.5 F
Normal pulse?
60-100 beats/minute
What are amplitude levels?
The strength of the pulse
What does 0 amplitude level mean?
pulse is absent
What does 1+ amplitude level mean?
Pulse is weak and can be obliterated easily
What does 2+ amplitude level mean?
Pulse is normal and can be obliterated with moderate pressure
What does 3+ amplitude level mean?
Pulse is bounding and cannot be obliterated without a lot of force
What is the apical site used for?
Taken for most accurate pulse/heart rate
What are normal pulse oximeter levels?
95% - 100%
What are some reasons a pulse ox reading can be lower?
Hypothermia, nail polish, decreased hemoglobin or patient is moving
What are normal amounts of respirations?
12-20 breaths/minute
What is a normal blood pressure?
120/80
What are Korotkoff's sounds?
Sounds you hear when taking someone's blood pressure
Explain each phase of Korotkoff's sounds?
Phase 1: repettive tapping; first tapping indicated systolic pressure
Phase 2: muffled/swishing sounds; can be present if patient is hypertensive
Phase 3: crisp and loud sounds indicating blood is rushing back
Phase 4: blowing sounds until all sounds disappear
Phase 5: last sound heard is the diastolic measurement
What is pulse pressure?
The difference between systolic and diastolic measurements
What does ADPIE stand for?
Assessment, diagnosis, planning, implementation, evaluation
What do you do in the assessment phase?
Collect subjective and objective data
