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 A
Explanation
Choice A reason: Mucolytics (e.g., acetylcysteine) break disulfide bonds in mucus, thinning it to ease expectoration, directly aiding secretion clearance in respiratory conditions.
Choice B reason: Glucocorticoids reduce inflammation in airways, not liquefying mucus; they address swelling, not viscosity, so they don’t facilitate expulsion directly.
Choice C reason: Calcium channel blockers relax vascular smooth muscle for hypertension, not affecting mucus consistency or respiratory secretions, irrelevant to this goal.
Choice D reason: Bronchodilators open airways, improving airflow, but don’t alter mucus viscosity, aiding breathing, not secretion liquefaction or removal specifically.
Correct Answer is A
Explanation
Choice A reason: NSTEMI causes chest pain at rest due to reduced blood flow from partial occlusion, unlike stable angina, reflecting demand-supply mismatch without full blockage.
Choice B reason: Complete occlusion causes ST-elevation MI (STEMI), not NSTEMI, which involves partial blockage, leading to subendocardial ischemia without full transmural infarction.
Choice C reason: Chest pain on exertion resolving with rest describes stable angina, not NSTEMI, which occurs unpredictably, often at rest, due to unstable plaque rupture.
Choice D reason: NSTEMI results from partial coronary occlusion, causing ischemia without ST elevation, detectable by troponin rise, distinguishing it from STEMI’s complete blockage.
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