ATI – Priority Setting Frameworks Beginning Test

A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse?
A) Malaise
B) Anorexia
C) Headache
D) Diarrhea
D) Diarrhea

A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first?
A) A client who has peripheral vascular disease and reports numbness in the toes
B) client who has depression & is easily distracted
C) A client who has Alzheimer’s disease and is unable to complete ADLS
D) A client who had abdominal surgery 10 days ago and reports feeling his incision pop
D) 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?

A) establishing a sense of achievement
B) contributing to society
C) creating meaningful social relationships
D) enhancing self- confidence

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?
A) Administer medications w/ meals when possible
B) Ensure client understanding of medication’s effects
C) Determine the client’s ability to self-administer meds
D) have the client position the head w/ chin down while swallowing
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?

A) Lithium carbonate 0.8
B) Digoxin 3.0
C) Peak serum gentamicin 6 mcg/mL
D) Mag. Sulfate 4

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?
A) Ensure all 4 side rails are up.
B) Administer a prescribed sedative.
C) Place the client in soft wrist restraints
D) Move the client to a room near the nurses’ station
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?

A) Place the infant in a supine position when sleeping
B) place the infant on a firm mattress when sleeping
C) avoid covering the infant with loose bedding while sleeping
D) avoid leaving stuffed animals in the crib with the sleeping infant

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?

A) obtain an ECG.
B) Administer oral potassium
C) Encourage potassium-rich foods
D)Monitor I & O

A) 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?
A) Place O2 at 2 L per nasal canula on the client
B) Place the client in the orthopneic position
C) Perform chest percussion
D) perform nasotracheal suction
B) Place the client in the orthopneic position

A nurse is collecting data on four clients. Which of the following findings is the most urgent?

A) bladder distension and urgency
B) pedal edema
C) warmth and pain in the calf
D) hypoactive bowel sounds

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?
A) Initiate oxygen therapy
B) encourage an increase in oral fluids
C) provide room humidification
D) Assist client to cough effectively
D) 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?
A) Provide assistance w/ ambulation when indicated
B) determine the mobility status of each patient
C) Maintain the side rails of each be in the raised position
D) Plan a fall prevention program for clients at risk
B) 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?
A) Cholesterol 220 mg/dL
B) Platelets 95,000 mm^3
C) BUN 20 mg/dL
D) Potassium 3.5 mEq/L
B) 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?
A) Check on the client
B) unlock the crash cart
C) begin cardiopulmonary resuscitation
D) announce a code
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?
A) providing pain control
B) preventing hemorrhage
C) maintaining a patent airway
D) ensuring adequate fluid intake
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?
A) immediate
B) delayed
C) minimal
D) expectant
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) a client who is has a history of HF
B) a client who has type 1 DM
C) a client who is reporting pain associated w/ osteoarthritis of the knees
D) a client who is having a nosebleed associated w/ hypertension
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?
A) obtain an arterial pH level
B) check the HR and Bp
C) insert an indwelling cath
D) collect a serum BUN and creatinine
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?
A) Administer an anticoagulant
B) Check the leg for warmth and Edema
C) Apply elastic stockings
D) Promote bed rest & extremity elevation
B) 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?

A) homelessness
B) lack of family support
C) Hypoxic
D) under nourished

Hypoxic

Enteral Nutrition is… Alternate form of feeding a client, & Given when client unable to ingest foods Enteral Access obtained by: -Nasogastric tubes -Nasointestinal (nasoenteric) tubes -Gastrostomy tubes -Jejunostomy tubes WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC …

A nurse is caring for an adult client who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states, “I keep seeing commercials on TV for …

A nurse is assessing a client who has diabetes mellitus and is experiencing foot pain. which of the following are signs and symptoms of infection? – increased neutrophils – localized edema A client is taking ibuprofen to treat hip pain. …

Priority Setting is the process of establishing a preferential sequence for addressing nursing diagnoses and interventions. The nurse and client begin planning by deciding which nursing diagnosis requires attention first, second, and so on. High Priority Life threatening problems – …

A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse …

The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first? 1. The client who has just been brought to the unit from the emergency department (ED) with no …

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