TEST BANK For Priorities in Critical Care Nursing, 9th
Edition by Linda D. Urden, Kathleen M. Stacy
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
Edition by Linda D. Urden, Kathleen M. Stacy
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
