ATI Priority Setting Frameworks Drills Prep Exam Questions And Answers All Correct.

Place the levels of Maslow's Hierarchy in the order in which they appear on the pyramid beginning with the level on the bottom of the pyramid at the bottom of the list and level at the apex of the pyramid at the top of the list. 1. Safety and security 2. Self-actualization 3. Love and belonging 4. Self-esteem 5. Physiological - correct answer 2. 4. 3. 1. 5. There are five levels of Maslow's Hierarchy of Needs. The foundation of the triangle represents physiological needs. The next level of the hierarchy is safety and security. Moving farther up the triangle are needs related to love and belonging and self-esteem with self-actualization at the apex of the triangle. When using the nursing process priority setting framework, the nurse should always remember to do which of the following first? a. Develop the client's plan of care b. Implement the client's plan of care c. Evaluate achievement of client goals d. Assess the client - correct answer d. Assess the client The most important thing to remember in relation to applying the nursing process as a priority setting framework is assessment first. Data is first gathered by assessing the client and is then analyzed to determine the most appropriate course of action and to develop the client's plan of care. After the plan of care has been developed, it should then be implemented. Following implementation of the plan of care, an evaluation is conducted to determine if decisions made about the course of action were appropriate so that adjustments in can be made to the plan as indicated. A nurse is caring for a client who is postoperative and whose airway is patent and respirations are 20 breaths per minute. Which of the following assessments should the nurse conduct in relation to the client's circulatory status? (Select all that apply.) a. Blood pressure b. Urinary output c. Amount of intravenous fluids received d. Skin turgor e. Pulse - correct answer a. Blood pressure b. Urinary output d. Skin turgor e. Pulse The nurse should evaluate the client's circulatory status by assessing the client's blood pressure, urinary output, skin turgor, and pulse. While the amount of intravenous fluids received will support the client's intravascular fluid volume, assessing the amount the client has received will not reflect the client's circulatory status in response to this amount. Which of the following can be used to help to determine the priority risk of a client who has multiple risks? (Select all that apply.) a. Maslow's Hierarchy of Needs b. Client's perception of priority risk c. Determining the complication that poses the highest risk d. Assessment of airway, breathing, and circulation needs e. Number of licensed and unlicensed nurses on RN's team - correct answer a. Maslow's Hierarchy of Needs c. Determining the complication that poses the highest risk d. Assessment of airway, breathing, and circulation needs When a nurse is determining the priority, risk of a client who has multiple risks, several frameworks may prove helpful in determining which risk is the priority risk. Determination of the complication that poses the greatest risk may also provide the nurse with a guideline regarding which risk must be addressed first. The client's perception of the priority risk may not be based on priorities that are related to the client's physiological or LPNs will not provide validation of the client's priority risk. A nurse is caring for a client who is confused and disoriented. The client has been getting out of the wheelchair when in her room and going into the bathroom without assistance. Which of the following interventions would be the least restrictive but most effective to use with this client? a. Wrist only restraints b. Wheelchair alarm c. Mattress beside the bed d. Mild sedative - correct answer b. Wheelchair alarm The least restrictive and most effective intervention would be to apply an alarm to the client's wheelchair that will alert the nurse when the client is trying to ambulate without assistance. A mattress beside the bed will protect the client from injury when getting out of bed but will not provide protection when the client is getting out of the wheelchair. The use of a mild sedative is a form of chemical restraint and should not be used unless specifically indicates by the provider. Any type of restraints, even wrist only restraints are a form of restrictive intervention and should not be used except on a temporary basis for clients who pose a significant safety risks to themselves or others. Interventions that are least invasive are desirable because of which of the following? (Select all that apply.) a. The number of organisms introduced into the body is reduced b. The risk of developing antibiotic resistant microbes is increased c. The incidence of hospital acquired infections will be increased d. The client's immune system may be compromised due to the stress of the illness e. The use of equipment that penetrates the body's natural barriers increases the client's risk for infection - correct answer a. The number of organisms introduced into the body is reduced d. The client's immune system may be compromised due to the stress of the illness e. The use of equipment that penetrates the body's natural barriers increases the client's risk for infection Interventions that are least invasive are desirable because the number of organisms introduced into the body is reduced, the client's immune system may be compromised due to the stress of the illness, and the use of equipment that penetrates the body's natural barriers increases the client's risk for infection. Interventions that are most invasive increase the risk of developing hospital acquired infections and antibiotic resistant microbes. A nurse is performing triage at a mass casualty event and is selecting a tag for a client who is severely injured and has no potential for survival. Which of the following tags should the nurse apply to the client? a. Class I b. Class II c. Class III d. Class IV - correct answer d. Class IV Clients whose injuries are extensive and not compatible with life, even wi