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 A

Explanation

A. A client with Parkinson’s disease who urgently needs to use the bathroom is at high risk for falls due to rigidity, tremors, and shuffling gait. Needing to move quickly to the bathroom further increases the risk of injury, making this the priority for immediate assessment and assistance.
B. Refusing bisphosphonate therapy for osteoporosis is important to address but does not present an immediate safety risk requiring urgent assessment.
C. A client who is 3 days post–hip fracture surgery requires ongoing monitoring, but this is expected care and not an immediate fall or injury risk compared with the Parkinson’s client.
D. An older adult ambulating may need monitoring for safety, but unless new symptoms arise, this does not pose the same level of urgency as the Parkinson’s client who needs urgent toileting.

A. Blood pressure 115/76 mmHg B. Heart rate 106 beats per minute C. Temperature to 101° Fahrenheit D. Respiratory rate of 18 breaths/min

Correct Answer is A

Explanation

A. An increase in blood pressure to 115/76 mmHg indicates improved circulating volume and perfusion, making this the best indicator of fluid status improvement.
B. A heart rate of 106 beats per minute remains elevated (tachycardia), which does not indicate improvement.
C. A temperature of 101°F reflects infection or fever, not hydration status.
D. A respiratory rate of 18 breaths/minute is within normal range but was already normal before fluids, so it is not the best indicator of fluid balance improvement.

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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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Naxlex Comprehensive Predictor Exams

The nurse is receiving morning report on several clients with mobility concerns. Which client is the priority for the nurse to assess?

Correct Answer is A

Explanation

The nurse is caring for a client with dehydration with vital signs as follows: blood pressure 96/72, heart rate 106, respiration rate of 18 breaths/minute, and temperature of 101F. After receiving intravenous fluids, which assessment finding is the best way to determine improvement in fluid status?

Correct Answer is A

Explanation

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