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 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.

A. Abdominal x-ray B. Shifting dullness C. Fluid wave D. Ultrasound

Correct Answer is D

Explanation

A. Abdominal x-ray: While it can show gas or bowel obstructions, it is less effective for confirming fluid presence.

B. Shifting dullness: This physical exam technique can indicate fluid but is less accurate than ultrasound.

C. Fluid wave: This physical exam can help suggest the presence of fluid, but it is also less reliable than imaging studies.

D. Ultrasound: An ultrasound is the most accurate and non-invasive way to confirm the presence of fluid, such as ascites, in the abdomen. It provides detailed imaging and confirmation without invasive procedures.

View Question and Answer

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

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

Assessment of a client reveals a distended abdomen with some bulging of the flanks. Which test would be most accurate in confirming nurse's suspicions?

Correct Answer is D

Explanation

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The absence of bowel sounds is established after listening for: