The RN has just received a change-of-shift report. Which client will the nurse assess first?

Client receiving peritoneal dialysis who needs help changing the dialysate bag.

Client with kidney insufficiency who is scheduled to have an arteriovenous fistula inserted.

Client with azotemia whose blood urea nitrogen and creatinine are increasing.

Client with chronic kidney failure who was just admitted with shortness of breath.

Answer and Explanation

The Correct Answer is D

In nursing prioritization, the ABC framework (Airway, Breathing, Circulation) is used to identify the most unstable patient. Chronic kidney failure patients are at high risk for fluid volume excess because their kidneys cannot excrete metabolic water or sodium. This can rapidly lead to pulmonary edema, where fluid leaks into the alveoli, causing life-threatening gas exchange impairment that requires immediate oxygenation, diuresis, or emergent dialysis.

Rationale:

A. Assisting with a peritoneal dialysis bag change is a routine task that does not represent an acute physiological emergency. While dialysis is important for long-term stability, it is a scheduled procedure for a stable patient. This task can be delayed or delegated to an appropriately trained staff member while the nurse addresses more urgent respiratory distress.

B. A client scheduled for an arteriovenous fistula insertion is likely stable and undergoing a planned surgical procedure. This patient requires preoperative teaching and preparation, but there is no indication of active hemodynamic or respiratory compromise. They do not take precedence over a patient experiencing acute symptoms of fluid overload and impaired breathing.

C. Azotemia and rising BUN/creatinine levels are expected findings in patients with renal insufficiency. While these trends require monitoring and eventual intervention, they do not indicate an immediate threat to the patient's life within the next few minutes. Lab values alone are secondary to the assessment of active, symptomatic clinical deterioration like respiratory distress.

D. The nurse must assess the client with shortness of breath first because it indicates potential pulmonary edema or metabolic acidosis. In the context of chronic kidney failure, new-onset dyspnea is a red flag for acute respiratory failure due to fluid overload. This patient requires immediate assessment of lung sounds and oxygen saturation to prevent respiratory arrest.

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Correct Answer is A

Explanation

Acute pancreatitisis an inflammatory condition characterized by the premature activation of digestive enzymes within the pancreas, leading to autodigestion. This process causes extensive tissue necrosis and hemorrhage, stimulating a massive inflammatory response. The resulting stimulation of visceral nociceptors in the retroperitoneum leads to intense, unrelenting pain that is often the primary reason patients seek emergency medical care.

Rationale:

A.Severe abdominal painis the hallmark and priority symptom of acute pancreatitis. This pain is typically described as "boring" and radiates to the back, caused by enzyme-mediated inflammation and peritoneal irritation. Managing this intense pain is a top priority because it causes significant physiological stress, including tachycardia and hypertension, and indicates the severity of the inflammatory process.

B.Nausea and vomiting are common symptoms of pancreatitis but are considered secondary to the inflammatory process and pain. While they contribute to fluid and electrolyte imbalances, they are not the "priority" problem that defines the clinical presentation. Pain management and fluid resuscitation are the primary therapeutic goals that take precedence over simple antiemetic therapy.

C.Jaundice and itching (pruritus) occur if the pancreatitis is caused by biliary obstruction (gallstones) or if the head of the pancreas compresses the common bile duct. However, these are not universal symptoms and are often delayed. They do not represent the acute, distressing priority that defines the initial presentation of pancreatic inflammation and autodigestion.

D.An elevated temperature is an expected part of the systemic inflammatory response in pancreatitis. However, fever is a clinical sign rather than a problem "reported" by the client as their primary concern. While the nurse monitors temperature to detect secondary infection or abscess, the client's most urgent and distressing report will always be the excruciating pain.

A. Pressure injury. B. Deep vein thrombosis. C. Jaundice. D. Hematemesis

Correct Answer is D

Explanation

The liver is the primary site for the synthesis of nearly all clotting factors, including the vitamin K-dependent factors (II, VII, IX, and X). In cirrhosis, the destruction of hepatocytes leads to a profound deficiency in these proteins, manifested as a prolonged prothrombin time(PT/INR). This coagulopathy, combined with thrombocytopenia from splenic sequestration, puts the patient at extreme risk for spontaneous and life-threatening gastrointestinal hemorrhage.

Rationale:

A.While patients with cirrhosis are at risk for pressure injuries due to malnutrition and edema, a prolonged prothrombin time does not directly increase the risk of skin breakdown. Pressure injuries are primarily a result of immobility and poor tissue perfusion. Coagulopathy is a hematologic failure that specifically predisposes the patient to bleeding rather than cutaneous ulceration.

B.Deep vein thrombosis (DVT) is a clotting disorder, which is the opposite of the bleeding risk indicated by a prolonged prothrombin time. A high PT means the blood takes longer than normal to clot, making the formation of a venous thrombus less likely compared to a healthy individual. The nurse's priority is monitoring for excessive bleeding, not excessive clotting.

C.Jaundice is a sign of impaired bilirubin metabolism and is an expected finding in cirrhosis, but it is not directly caused by a prolonged prothrombin time. While both symptoms result from liver failure, they represent different functional deficits (pigment excretion vs. protein synthesis). Jaundice is not an acute, life-threatening manifestation of a high prothrombin time.

D.The nurse must monitor for hematemesis(vomiting blood) because a prolonged prothrombin time indicates a severe bleeding risk. In cirrhosis, this is often compounded by esophageal varicescaused by portal hypertension. A patient with poor clotting ability who develops a variceal bleed can quickly exsanguinate, making the detection of GI bleeding the highest clinical priority.

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The RN has just received a change-of-shift report. Which client will the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report?

Correct Answer is A

Explanation

The nurse is caring for a client who has cirrhosis of the liver. The client’s latest laboratory testing shows a prolonged prothrombin time. For what assessment finding would the nurse monitor:

Correct Answer is D

Explanation

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