Test Bank - Priorities in Critical Care Nursing, 8th Edition
(Lough, 9780323531993), Chapter 1-27 | Rationals Included
A nurse is assessing a client using the ABCDE priority-setting approach. Which of the following actions
should the nurse take when completing the exposure component of this priority setting method?
(Select all that apply.) - ANSWER: Observe the client's lower extremities for indications of deep vein
thrombosis.
Measure the client's temperature.
Check the client for bruising.
A nurse has received change-of-shift report on four clients. Which of the following clients should the
nurse plan to see first? - ANSWER: A client who has audible wheezing during respirations
A nurse is prioritizing care for a client. Identify the priority order of client needs using Maslow's
Hierarchy of Needs. (Move the levels into the box on the right, placing them in the order of priority.
Use all the levels.) - ANSWER: Physiological
Safety
Love/Belonging
Esteem
Self-actualization
A nurse is caring for a client who is experiencing unexpected manifestations with several body
systems. Which of the following priority setting frameworks should the nurse use to prioritize client
assessment? - ANSWER: ABCDE
A nurse is performing an admission assessment on a client. Using the safety and risk reduction priority
setting framework, which of the following findings should the nurse identify as the priority? -
ANSWER: The client reports dizziness when standing
A nurse is caring for a client who reports new onset of abdominal pain. The nurse should assign the
client's condition to which of the following categories when prioritizing care? - ANSWER: Urgent
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? - ANSWER: A client who has an abdominal
wound that is actively bleeding
A nurse is reviewing the medical records of four clients. Which of the following clients should the
nurse identify as the priority for care? - ANSWER: A client who received digoxin and has a heart rate
of 48/min
A nurse is admitting a client who has hypertension. Using the nursing process, which of the following
actions should the nurse take first? - ANSWER: Perform a physical assessment
A nurse is providing education on priority setting frameworks to a group of newly licensed nurses.
Which of the following statements should the nurse make regarding the safety and risk reduction
priority setting framework? - ANSWER: "This framework assigns the highest priority to the situation
that poses a threat to the client's physical well-being."
A nurse is caring for a client who is confused and trying to remove their peripheral IV. Using the least
restrictive/least invasive priority setting framework, which of the following actions should the nurse
take first? - ANSWER: Cover the IV site with an elastic bandage.
, 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? - ANSWER: Self-esteem
A nurse is assessing a client using the ABCDE approach. The nurse has already assessed the client's
airway and breathing status. Which of the following assessments should the nurse perform next? -
ANSWER: Blood pressure
A nurse at a provider's office is reviewing the records of several clients. Which of the following clients
should the nurse recommend as the priority for treatment? - ANSWER: A client who reports new
chest pain
A nurse has received change-of-shift report for a group of clients. Which of the following clients
should the nurse plan to see first? - ANSWER: A client who is receiving a blood transfusion and reports
urticaria
A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the
following hand hygiene methods should the nurse use? - ANSWER: Soap and water
A nurse is wearing gloves while caring for a client. In which of the following situations should the
nurse obtain a new pair of gloves? - ANSWER: After changing a dressing on the client and before
documenting findings on a computer
A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the
following instructions should the nurse include? - ANSWER: Report needlestick injuries to the nursing
supervisor.
A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of
which of the following links in the chain of infection? - ANSWER: Susceptible host
A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse
should include in the teaching that tuberculosis is transmitted by which of the following modes of
transmission? - ANSWER: Airborne
A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate
generalized inflammation. The nurse should include which of the following laboratory tests? -
ANSWER: C-reactive protein
A nurse is caring for a client who is on contact precautions. Which of the following actions should the
nurse take? - ANSWER: Place the client in a private room.
A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following
statements should the nurse make? - ANSWER: "Remove nail polish on your fingernails if it is
chipped."
A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should
include in the teaching that which of the following types of precautions requires the use of an N95
mask? - ANSWER: Airborne
A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-
associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse
include in the bundle? - ANSWER: Try to use alternatives before inserting indwelling urinary catheters.
A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by
the newly licensed nurse indicates an understanding of the procedure? - ANSWER: Turns off the
faucet with a towel
(Lough, 9780323531993), Chapter 1-27 | Rationals Included
A nurse is assessing a client using the ABCDE priority-setting approach. Which of the following actions
should the nurse take when completing the exposure component of this priority setting method?
(Select all that apply.) - ANSWER: Observe the client's lower extremities for indications of deep vein
thrombosis.
Measure the client's temperature.
Check the client for bruising.
A nurse has received change-of-shift report on four clients. Which of the following clients should the
nurse plan to see first? - ANSWER: A client who has audible wheezing during respirations
A nurse is prioritizing care for a client. Identify the priority order of client needs using Maslow's
Hierarchy of Needs. (Move the levels into the box on the right, placing them in the order of priority.
Use all the levels.) - ANSWER: Physiological
Safety
Love/Belonging
Esteem
Self-actualization
A nurse is caring for a client who is experiencing unexpected manifestations with several body
systems. Which of the following priority setting frameworks should the nurse use to prioritize client
assessment? - ANSWER: ABCDE
A nurse is performing an admission assessment on a client. Using the safety and risk reduction priority
setting framework, which of the following findings should the nurse identify as the priority? -
ANSWER: The client reports dizziness when standing
A nurse is caring for a client who reports new onset of abdominal pain. The nurse should assign the
client's condition to which of the following categories when prioritizing care? - ANSWER: Urgent
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? - ANSWER: A client who has an abdominal
wound that is actively bleeding
A nurse is reviewing the medical records of four clients. Which of the following clients should the
nurse identify as the priority for care? - ANSWER: A client who received digoxin and has a heart rate
of 48/min
A nurse is admitting a client who has hypertension. Using the nursing process, which of the following
actions should the nurse take first? - ANSWER: Perform a physical assessment
A nurse is providing education on priority setting frameworks to a group of newly licensed nurses.
Which of the following statements should the nurse make regarding the safety and risk reduction
priority setting framework? - ANSWER: "This framework assigns the highest priority to the situation
that poses a threat to the client's physical well-being."
A nurse is caring for a client who is confused and trying to remove their peripheral IV. Using the least
restrictive/least invasive priority setting framework, which of the following actions should the nurse
take first? - ANSWER: Cover the IV site with an elastic bandage.
, 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? - ANSWER: Self-esteem
A nurse is assessing a client using the ABCDE approach. The nurse has already assessed the client's
airway and breathing status. Which of the following assessments should the nurse perform next? -
ANSWER: Blood pressure
A nurse at a provider's office is reviewing the records of several clients. Which of the following clients
should the nurse recommend as the priority for treatment? - ANSWER: A client who reports new
chest pain
A nurse has received change-of-shift report for a group of clients. Which of the following clients
should the nurse plan to see first? - ANSWER: A client who is receiving a blood transfusion and reports
urticaria
A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the
following hand hygiene methods should the nurse use? - ANSWER: Soap and water
A nurse is wearing gloves while caring for a client. In which of the following situations should the
nurse obtain a new pair of gloves? - ANSWER: After changing a dressing on the client and before
documenting findings on a computer
A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the
following instructions should the nurse include? - ANSWER: Report needlestick injuries to the nursing
supervisor.
A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of
which of the following links in the chain of infection? - ANSWER: Susceptible host
A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse
should include in the teaching that tuberculosis is transmitted by which of the following modes of
transmission? - ANSWER: Airborne
A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate
generalized inflammation. The nurse should include which of the following laboratory tests? -
ANSWER: C-reactive protein
A nurse is caring for a client who is on contact precautions. Which of the following actions should the
nurse take? - ANSWER: Place the client in a private room.
A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following
statements should the nurse make? - ANSWER: "Remove nail polish on your fingernails if it is
chipped."
A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should
include in the teaching that which of the following types of precautions requires the use of an N95
mask? - ANSWER: Airborne
A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-
associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse
include in the bundle? - ANSWER: Try to use alternatives before inserting indwelling urinary catheters.
A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by
the newly licensed nurse indicates an understanding of the procedure? - ANSWER: Turns off the
faucet with a towel
