A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available for use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dL (15 g/L). Which intervention is the priority for the nurse to implement?

Serum Albumin Reference Range: 3.5 to 5.5 g/dL (35 to 55 g/L)

Choice A: Client’s healthcare power of attorney. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The healthcare power of attorney is a legal document that designates who can make medical decisions for the client if they are unable to do so themselves.

Choice B: Currently prescribed medications. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The currently prescribed medications are a part of the background information that can help explain the client’s medical history and potential causes of confusion.

Choice C: Fall at home as reason for admission. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The fall at home is a part of the background information that can help explain the client’s reason for admission and potential injuries.

Choice D: Increasing confusion of the client. This is the first information that the nurse should provide, as it addresses the current situation or problem of the client. The increasing confusion of the client is a part of the assessment information that can help identify the urgency and severity of the issue and guide further interventions.

Choice A: A 14-year-old client with anorexia nervosa refusing to eat the evening snack is a concern, but it’s not an immediate threat. The nurse can address this issue after dealing with more urgent situations.

Choice B: An 18-year-old client with antisocial behavior being yelled at by other clients requires immediate attention. This situation can escalate quickly and may lead to physical harm or emotional distress for the client.

Choice C: A 16-year-old client diagnosed with major depression refusing to participate in group is a concern, but it’s not an immediate threat. The nurse can address this issue after dealing with more urgent situations.

Choice D: A 17-year-old client diagnosed with bipolar disorder pacing around the lobby might be experiencing agitation or restlessness, but unless they’re showing signs of immediate distress or posing a risk to themselves or others, it’s not the most urgent situation.