The nurse is assessing a client with chronic kidney disease. Which assessment finding is the priority for the nurse to report?

Weight gain of 3 pounds in 24 hours

Decreased muscle strength

BUN 28 mg/dL (Ref: 10-20 mg/dL)

Bilateral 2+ pedal pulses

Answer and Explanation

The Correct Answer is A

A. A weight gain of 3 pounds in 24 hours indicates fluid retention, which can quickly progress to fluid overload, pulmonary edema, and heart failure. This is the priority finding to report.
B. Decreased muscle strength may occur due to electrolyte imbalance or fatigue but is not immediately life-threatening.
C. An elevated BUN is expected in chronic kidney disease and is not as urgent as acute fluid retention.
D. Bilateral 2+ pedal pulses are normal and do not require reporting.

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Correct Answer is C

Explanation

A. Renal calculi (kidney stones) can cause flank pain and hematuria, but this client’s systemic infection signs (fever, tachycardia, chills, elevated WBC) point toward a urinary tract infection progressing to pyelonephritis, not stones.

B. A CT scan might be used later to assess for obstruction or complications, but it is not the first step. Immediate diagnostic confirmation of infection is needed.

C. The client’s presentation strongly suggests acute pyelonephritis (upper urinary tract infection with systemic involvement). A urinalysis and urine culture are the priority initial diagnostic tests to confirm infection and guide treatment. This should be done before starting antibiotics whenever possible.

D. An EKG may be indicated in cases of electrolyte imbalance (e.g., hyperkalemia in renal failure), but this client’s electrolytes and creatinine are within range. It is not a priority at this time.

A. Keep the client in a low stimulus environment B. Assist with lumbar puncture C. Administer the meningococcal vaccine for treatment. D. Initiate intravenous antibiotics E. Assess neurologic status daily F. Implement seizure precautions G. Implement droplet precautions

Correct Answer is ["A","B","D","F","G"]

Explanation

A. A low-stimulation environment helps reduce discomfort and agitation, which is important for clients with meningitis.

B. Assisting with a lumbar puncture is essential for confirming the diagnosis and guiding treatment.

C. The meningococcal vaccine is preventive, not a treatment for active infection. Antibiotics are the primary treatment.

D. Intravenous antibiotics should be initiated immediately to treat bacterial meningitis and reduce morbidity and mortality.

E. While assessing neurologic status is important, daily assessment alone is insufficient; continuous monitoring and early interventions are priority.

F. Seizure precautions are important because meningitis can increase the risk of seizures due to irritation of the meninges.

G. Droplet precautions are necessary to prevent transmission of Neisseria meningitidis, which is highly contagious.

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Blood Pressure	118/78 mmHg
Heart Rate	112 beats/minute
Respiratory Rate	22 breaths/minute
Temperature	102.8 F (39.3 C)
WBC	16000 (Ret: 4000-11000)
BUN	24 mg/dL (Ref: 8-20 mg/dL)
Creatinine	1.1 mg/dL (Ref: 0.6-1.2 mg/dL)

The nurse is assessing a client with chronic kidney disease. Which assessment finding is the priority for the nurse to report?

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Correct Answer is C

Explanation

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Correct Answer is ["A","B","D","F","G"]

Explanation

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