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 C
Explanation
Choice A reason: Stopping speech entirely suggests advanced Alzheimer’s or aphasia, not mild, where memory and task performance decline first, not communication fully.
Choice B reason: Difficulty with toothbrush and comb indicates moderate Alzheimer’s, where motor apraxia emerges, beyond mild stage’s primary memory issues.
Choice C reason: Forgetfulness and slower task completion reflect mild Alzheimer’s early memory loss and executive dysfunction, impairing planning, consistent with initial stages.
Choice D reason: Bladder and bowel incontinence occur in late Alzheimer’s from severe brain damage, not mild, where cognitive, not physical, decline predominates.
Correct Answer is D
Explanation
Choice A reason: Working in undeveloped areas increases general infection risk, but hepatitis B specifically requires blood or fluid exposure, less likely without direct contact.
Choice B reason: Attending a conference poses low hepatitis B risk, as it’s not spread by casual contact, requiring blood or sexual transmission, not typical here.
Choice C reason: Assisting in birth involves fluid exposure, but two weeks is too short for hepatitis B symptoms; incubation is 45-180 days, so unlikely.
Choice D reason: Tattooing with unsterile needles risks hepatitis B via bloodborne transmission, matching the 90-day incubation period, the most likely risk here.
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