The nurse is caring for four clients with chronic kidney disease (CKD). Which client would the nurse assess first during initial rounding?

Choice A reason: Pruritus (itching) is a common, distressing symptom of CKD caused by the buildup of uremic toxins and calcium-phosphate deposits in the skin. While it significantly impacts the client's comfort and skin integrity, it is not an acute respiratory or metabolic emergency that takes precedence over airway and breathing. Choice B reason: Kussmaul respirations are deep, rapid, labored breaths that indicate the body is attempting to blow off carbon dioxide to compensate for severe metabolic acidosis. In CKD, this signals a dangerous failure of the kidneys to excrete hydrogen ions. This respiratory pattern indicates a critical physiological imbalance that requires immediate medical intervention. Choice C reason: Halitosis (uremic fetor) and stomatitis (inflammation of the oral mucosa) occur in advanced CKD due to the breakdown of urea into ammonia by salivary enzymes. While these symptoms are unpleasant and indicate high levels of systemic waste, they do not represent an immediate threat to the client’s life-sustaining functions. Choice D reason: A blood pressure of 158/90 mm Hg is elevated and typical for a client with CKD due to fluid retention and renin-angiotensin-aldosterone system activation. While hypertension must be managed to prevent further renal damage and cardiovascular events, it is not as acutely life-threatening as the severe metabolic acidosis indicated by Kussmaul breathing.