A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention?
A. A client who has cystic fibrosis and has a paroxysmal cough
B. A client who is prescribed cromolyn sodium (Crolom) and has a peak expiratory flow rate of 79%
C. A client who h...
ATI Nurse Logic 2.0 ~ Priority Setting
Frameworks (Advanced Test)Questions
Fully Answered.
A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate
intervention?
A. A client who has cystic fibrosis and has a paroxysmal cough
B. A client who is prescribed cromolyn sodium (Crolom) and has a peak expiratory flow rate of 79%
C. A client who has celiac disease and abdominal distention
D. A client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting - Answer D. A
client who is prescribed digoxin (Lanoxin) and has had three episodes of vomiting
Rationale:
A. Answering this item requires application of the acute versus chronic priority setting framework. Using
this framework, acute needs are typically the priority need because they pose more of a threat to the
client. Because chronic needs usually develop over a period of time, the client has more of an
opportunity to adapt to the alteration in health. It is also important to attend to alterations when they
are in the acute phase so they don't escalate into a life-threatening event or evolve into a chronic
alteration in health. Nursing knowledge might also be needed to determine which option describes an
acute need. A paroxysmal cough is a clinical manifestation associated with cystic fibrosis, which is a
chronic condition. While the client should be further evaluated, there is another client who has more
acute needs that requires immediate intervention.
B. Answering this item requires application of the acute versus chronic priority setting framework. Using
this framework, acute needs are typically the priority need because they pose more of a threat to the
client. Because chronic needs usually develop over a period of time, the client has more of an
opportunity to adapt to the alteration in health. It is also important to attend to alterations when they
are in the acute phase so they don't escalate into a life-threatening event or evolve into a chronic
alteration in health. Nursing knowledge might also be needed to determine which option describes an
acute need. Cromolyn sodium is a nonsteroidal anti-inflammatory medication used as an asthma
prophylactic. A peak expiratory flow rate of 79% is below the expected rate and signals the possibility
that asthma is not well-controlled. While the client should be further evaluate
A nurse working the 7 p.m. to 7 a.m. shift on a pediatric unit has received report on four postoperative
clients. Which of the following requires immediate intervention?
,A. An adolescent who is postoperative following an appendectomy and has refused to ambulate for the
past 8 hr
B. A school-age child who is postoperative following a herniorrhaphy with an infiltrated peripheral IV
that has been clamped
C. A preschooler who is postoperative following a tonsillectomy and is experiencing frequent swallowing
D. An infant who is postoperative following a cleft palate repair with a heart rate of 146/min and a
respiratory rate of 28/min - Answer C. A preschooler who is postoperative following a tonsillectomy
and is experiencing frequent swallowing
Rationale:
A. Answering this item requires application of the unstable versus stable priority setting framework.
Using this framework, unstable clients get priority because of needs that threaten the client's survival.
Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening
needs that should be addressed first. Clients whose vital signs or laboratory values indicate a risk for
becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also
be needed to determine which option describes the most unstable client. An adolescent who refuses to
ambulate following abdominal surgery needs additional education and encouragement; however, there
is another client who is unstable and requires immediate intervention.
B. Answering this item requires application of the unstable versus stable priority setting framework.
Using this framework, unstable clients get priority because of needs that threaten the client's survival.
Threats or problems involving the airway, breathing, or circulatory status are considered life-threatening
needs that should be addressed first. Clients whose vital signs or laboratory values indicate a risk for
becoming unstable are also a higher priority than clients who are stable. Nursing knowledge might also
be needed to determine which option describes the most unstable client. An infiltrated peripheral IV
needs to be discontinued and another IV started; however, because the IV tubing has been clamped,
stopping the infusion of fluids, there is another client who is unstable and requires immediate
intervention.
C. Answering this item requires application of the unstable versus stable priority setting framework.
Using t
A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis.
Which of the following is the nurse's priority concern?
A. Promoting oxygenation
B. Management of pain
, C. Maintaining hydration
D. Preventing infection - Answer A. Promoting oxygenation
Rationale:
A. Answering this item requires application of the ABC priority setting framework, which emphasizes the
basic core of human functioning - having an open airway, being able to breathe in adequate amounts of
oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can
indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority
setting framework, airway is always the highest priority because the airway must be clear and open for
oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework
because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the
third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs
only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Using the
ABC priority setting framework, maintaining a patent airway and ensuring adequate respiratory effort are
the priority concerns of the nurse caring for a client who has been admitted in a vaso-occlusive crisis.
Short-term oxygen therapy is used to prevent additional sickling and hypoxia. Massive systemic sickling
has been linked to severe hypoxia and can be fatal. Rest should also be encouraged to decrease
expenditure of energy and oxygen. Based on this knowledge and using the ABC priority setting
framework, promoting oxygenation is the nurse's priority concern.
B. Answering this item requires application of the ABC priority setting framework, which emphasizes the
basic core of human functioning - having an open airway, being able to breathe in adequate amounts of
oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these ca
A nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions
should the nurse take first?
A. Administer an anti-anxiety medication.
B. Take the client to a place of seclusion.
C. Obtain an order for soft wrist restraints.
D. Engage the client in physical activity. - Answer D. Engage the client in physical activity.
Rationale:
A. Answering this item requires application of the least restrictive, least invasive priority setting
framework. This framework assigns priority to nursing interventions that are least restrictive and least
invasive to the client, as long as those interventions do not jeopardize client safety. Least restrictive
interventions promote client safety without using restraints. Physical or chemical restraints should only
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