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Priority Setting Frameworks - Beginner Test Q & A

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Priority Setting Frameworks - Beginner Test Q & A A nurse is collecting data on four clients. Which of the following findings is the most urgent? Warmth and pain in the calf Rationale: Using the urgent versus non-urgen ...

Priority Setting Frameworks - Beginner Test Q & A A nurse is collecting data on four clients. Which of the following findings is the most urgent? Warmth and pain in the calf Rationale: Using the urgent versus non-urgent priority setting framework, the most urgent finding is warmth and pain in the calf of a client. Warmth and pain in the calf is indicative of deep-vein thrombosis, which places the client at risk for pulmonary embolism. Using the urgent versus non-urgent priority setting framework and nursing knowledge, this is the finding that represents the most urgent need. This option is further supported by the ABC priority setting framework. 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 client. 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 Rationale: This platelet level is below the expected reference range and indicates the client is at risk for bleeding. Based on the stable versus unstable priority setting framework and nursing knowledge, the client with this laboratory value requires immediate intervention. *** A normal platelet count ranges from 150,000 to 450,000 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 nurse is caring for a client who is in the immediate postoperative period following a tracheotomy. Which of the following is the nurse's priority action? Maintaining a patent airway

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