ATI Priority Setting Frameworks Beginning
A nurse is collecting data on 4 clients. Which of the following has the highest priority finding by the
... [Show More] nurse?
Malaise
Anorexia
Headache
Diarrhea - correct answer Diarrhea
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 the highest priority because the airway must be open and clear 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 circulation is the nurse's priority concern. Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood volume. Based on this knowledge and using the ABC priority setting framework, this is the highest priority finding by the nurse.
A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first?
A client who has peripheral vascular disease and reports numbness in the toes
A client who has depression and is easily distracted
A client who has Alzheimer's disease and is unable to complete activities of daily living
A client who had abdominal surgery 10 days ago and reports feeling his incision pop - correct answer A client who had abdominal surgery 10 days ago and reports feeling his incision pop [Show Less]