Question

a nurse is collecting data on a client using the abcde priority - setting approach. which of the following actions should the nurse take when completing the exposure component of this priority setting approach? (select all that apply.)
observe the clients lower extremities for indications of deep vein thrombosis.
obtain a respiratory rate for one full minute.
measure the clients temperature
check the client for bruising.
obtain a blood pressure measurement.

Explanation:

In the ABCDE priority - setting approach, the "E" stands for exposure. This involves looking for signs of environmental or internal factors that could harm the client. Observing for deep - vein thrombosis and checking for bruising are part of looking for internal issues that could be a risk to the client. Measuring temperature can also be related to identifying internal problems like infection. Obtaining a respiratory rate is part of the "A" (airway) and "B" (breathing) components, and getting a blood pressure measurement is part of the "C" (circulation) component.

Answer:

Observe the client's lower extremities for indications of deep vein thrombosis.
Measure the client's temperature
Check the client for bruising.