The nurse is caring for the following clients. Which client should the nurse assess first?
A 60-year-old client who has end-stage renal disease with a creatinine of 5.1
A 50-year-old client who has chronic pancreatitis and is reporting a pain level of 6 out of 10
A 54-year-old client with cirrhosis and jaundice who is reporting itchiness and drowsiness
A 47-year-old client with esophageal varices and influenza and has been coughing for 30 minutes
The Correct Answer is D
Choice A reason: Creatinine 5.1 in ESRD is chronic, not acute, and stable unless symptomatic; it’s less urgent than potential bleeding risks in other clients.
Choice B reason: Pain (6/10) in pancreatitis is significant but not immediately life-threatening compared to airway or bleeding risks, manageable with scheduled interventions.
Choice C reason: Itchiness and drowsiness in cirrhosis suggest liver dysfunction, concerning but not acute threats like variceal rupture, prioritizing more critical symptoms.
Choice D reason: Coughing with esophageal varices risks rupture and massive bleeding, a life-threatening emergency, making this client the priority for immediate assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Increasing oxygen to 3 L/min may help but risks CO2 retention in COPD without assessing respiratory rate, depth, and saturation first, making it premature.
Choice B reason: Coughing clears secretions, but without assessing respiratory status, it’s unclear if secretions are the issue or if the client can effectively cough, so it’s not priority.
Choice C reason: Calling emergency services assumes severity without data like oxygen saturation or distress level, delaying care by skipping initial assessment in this stable setting.
Choice D reason: Assessing respiratory status (rate, oxygen saturation, lung sounds) identifies the cause of difficulty, guiding interventions like oxygen adjustment or escalation, per ABC priority.
Correct Answer is D
Explanation
Choice A reason: Renin, from the kidneys, regulates blood pressure via angiotensin, not a thyroid product, unrelated to its metabolic or calcium functions.
Choice B reason: BNP, secreted by the heart, reduces volume overload in heart failure, not a thyroid hormone, distinct from its endocrine role.
Choice C reason: Erythropoietin, from kidneys, stimulates red blood cell production, not produced by the thyroid, which focuses on metabolism and calcium.
Choice D reason: Calcitonin, from thyroid parafollicular cells, lowers blood calcium by inhibiting bone resorption, a key thyroid hormone alongside T3/T4.
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