The nurse is caring for four patients with chronic kidney disease. Which patient would the nurse assess first upon initial rounding?
a) Woman with a blood pressure of 158/90 mm Hg.
b) Patient with Kussmaul respirations.
c) Man with skin itching from head to toe.
d) Patient with halitosis and stomatitis.

The correct answer is: b) Patient with Kussmaul respirations.


Choice A reason: A blood pressure of 158/90 mm Hg in a patient with chronic kidney disease (CKD) is elevated and requires management to prevent complications. However, it is not as immediately life-threatening as Kussmaul respirations, which indicate severe metabolic acidosis.
Choice B reason: The patient with Kussmaul respirations should be assessed first. Kussmaul respirations are deep, labored breathing patterns typically associated with severe metabolic acidosis, such as diabetic ketoacidosis (DK

Choice A reason: An increase in urine output to 35 mL/hr is the best indication of improved perfusion. Urine output is a direct measure of kidney function and perfusion. When the kidneys receive adequate blood flow, they are able to produce urine. An increase in urine output indicates that the patient's kidneys are being perfused more effectively, which is a reliable sign of overall improved perfusion status.

Choice B reason: A decrease in heart rate to 105 beats/min is a positive sign, as it indicates a reduction in the stress response and an improvement in hemodynamic status. However, it is not as direct an indicator of improved perfusion as urine output. Heart rate can be influenced by many factors, and while a lower heart rate is generally a good sign, it does not specifically indicate improved organ perfusion.

Choice C reason: An increase in systolic blood pressure to 85 mmHg is an indication of improved hemodynamic stability, but it is not as sensitive a measure of perfusion as urine output. Blood pressure provides information about the pressure within the arteries but does not directly indicate how well the organs and tissues are being perfused.

Choice D reason: A decrease in right atrial pressure is not typically an indicator of improved perfusion. Right atrial pressure reflects the pressure in the right atrium of the heart, which can be influenced by various factors, including fluid status and cardiac function. It is not a direct measure of perfusion to vital organs and tissues.

Choice A reason: While performing a daily full head-to-toe assessment is important in comprehensive patient care, this answer does not specifically address why the nurse would be particularly concerned with assessing the abdomen in a burn patient.

Choice B reason: Assessing for a paralytic ileus secondary to reduced blood flow is crucial in patients with serious burns. Burns can lead to significant physiological stress, which can decrease blood flow to the gastrointestinal tract. This reduction in blood flow can cause a paralytic ileus, a condition where the intestines do not move properly, leading to abdominal distention, pain, and decreased bowel sounds. Early detection is vital to prevent complications.

Choice C reason: While nausea and vomiting related to pain medication are possible in burn patients, the primary concern in assessing the abdomen would be to identify more serious conditions such as a paralytic ileus. This answer does not capture the immediate criticality compared to assessing for paralytic ileus.

Choice D reason: Monitoring for increased motility that may result in cramps and diarrhea is not the primary concern in burn patients. In fact, burn patients are more likely to experience decreased gastrointestinal motility due to the stress response and reduced blood flow rather than increased motility.