ATI Video Case Study: Priority Setting questions and answers scored A+

ATI Video Case Study: Priority Setting questions and answers scored A+ A nurse is preparing to apply a condom catheter to a male client. Which of the following actions should the nurse take after performing hand hygiene and applying clean gloves? Check the condition of the penile shaft. *The first action the nurse should take when using the nursing process is assessment. To maintain safety and prevent injury to the client by taking the necessary precautions, the nurse should check the condition of the client's skin to determine a baseline. The nurse should then monitor the client's skin for redness, swelling, or lesions. A nurse enters a client's room and sees the client lying on the floor next to the bed. Which of the following actions should the nurse take first? Obtain the client's vital signs. *The greatest risk to this client is injury from falling out of bed; therefore, the first action for the nurse to take is to obtain the client's vital signs to verify that the client is stable. A nurse is assessing four clients. Which of the following clients should the nurse assess first? A client who has a chest tube and has asymmetrical chest movement *When using the acute versus chronic approach to client care, the nurse should place the priority on the client who has a chest tube and has asymmetrical chest movement because this can indicate a tension pneumothorax. A nurse is assessing a client who has cancer and is receiving morphine for pain management. Which of the following findings is the nurse's priority? Respiratory rate 10/min *The nurse should identify that the respiratory rate of 10/min is the priority finding by using the airway, breathing, circulation approach to client care. A respiratory rate of 10/min is an indication of toxicity. The nurse should not administer the next dose of medication and should notify the provider immediately. A nurse is the PACU is caring for a client who is postoperative following an abdominal hysterectomy. Which of the following actions should the nurse take first? Place the client in a side-lying position. *The greatest risk to this client is injury from an obstructed airway; therefore, the first action the nurse should take is to place the client in a side-lying position to allow her tongue to fall to the side of her mouth, instead of having her tongue obstruct her airway.