The nurse in the dialysis unit is initiating the morning scheduled dialysis clients. Which client would the nurse prioritize to assess first?

The client on peritoneal dialysis who is reporting a hard and rigid abdomen.

The client who does not have a palpable thrill or auscultated bruit.

The client who is reporting a 3.6 kg weight gain and it refusing dialysis.

The client who has a hemoglobin of 9.0 mg/dL (12.0-15.5 mg/dL) and hematocrit of 26% (36.1% -44.3%).

Answer and Explanation

The Correct Answer is A

A. The client on peritoneal dialysis who is reporting a hard and rigid abdomen. A hard, rigid abdomen suggests peritonitis, a life-threatening complication requiring immediate assessment and intervention.

B. The client who does not have a palpable thrill or auscultated bruit: This indicates a possible vascular access issue, but it is not as immediately life-threatening as peritonitis.

C. The client who is reporting a 3.6 kg weight gain and refusing dialysis: This weight gain could signal fluid overload, but refusal of dialysis would require a different approach that may not need immediate intervention unless symptoms worsen.

D. The client with a hemoglobin of 9.0 mg/dL and hematocrit of 26%: This low hemoglobin and hematocrit level may require treatment, but it is not an immediate life-threatening issue like peritonitis.

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Correct Answer is B

Explanation

A. Positive Skin Hypersensitivity Test: This is incorrect as it typically involves pain or discomfort with light touch, unrelated to rebound tenderness.

B. Positive Rovsing Sign: A positive Rovsing sign occurs when pain is felt in the right lower quadrant upon palpation of the left lower quadrant, indicating possible appendicitis.

C. Psoas Sign: This is elicited by extending the hip, and a positive sign indicates irritation of the iliopsoas muscle, often seen in appendicitis.

D. Positive Obturator Sign: This involves internal rotation of the hip, also used in appendicitis assessments but involves different positioning.

A. When did your pain symptoms begin?" B. "Do you think you know what caused the swelling? C. "What brings you to the clinic today?" D. "Can you go over what you said about nothing relieving the pain?

Correct Answer is A

Explanation

A. "When did your pain symptoms begin?" When conducting a focused assessment on pain, the nurse should gather specific details about the onset, location, duration, characteristics, and aggravating/relieving factors. Asking when the pain symptoms began helps clarify the onset, which is critical in assessing the pain's cause and severity.

B. "Do you think you know what caused the swelling?": This is less focused on pain and more on swelling, which may not be the client's main concern.

C. "What brings you to the clinic today?": While this is a good general question, it is not focused on pain and would not gather specific pain-related information.

D. "Can you go over what you said about nothing relieving the pain?": This question is not as open-ended or specific to a focused pain assessment as asking about onset.

What subjective assessment information in this client situation is the most important and immediate concern for the nurse?

View Question and Answer

The nurse in the dialysis unit is initiating the morning scheduled dialysis clients. Which client would the nurse prioritize to assess first?

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Naxlex Comprehensive Predictor Exams

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding?

Correct Answer is B

Explanation

The nurse is conducting a focused assessment of a client who is experiencing pain. Which question should the nurse ask the client?

Correct Answer is A

Explanation

The absence of bowel sounds is established after listening for:

The client is brought into the emergency room (ER) by paramedics with blunt trauma to the left upper side of the abdomen due to a motor vehicle accident. The ER nurse knows what organ is most likely impacted.

The nurse in the dialysis unit is initiating the morning scheduled dialysis clients. Which client would the nurse prioritize to assess first?

A client's bladder is found to be distended. At which location would the nurse begin palpating?

A nurse at a long-term care facility is assessing a client who just received hearing aids. Which of the following actions should indicate to the nurse that the client understands how to use the hearing aids? (Select all that apply.)

The nurse receives the primary provider's order of phenytoin 0.2 g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer. (Round to the nearest whole number)

When inspecting a client's abdominal contour, the nurse observes the abdomen to be sunken with the lower edges of the ribs visible. The nurse documents this as which of the following?