A client has been admitted into the Dialysis unit to rule out a peritoneal infection. Which of the following clinical findings should the nurse be MOST concerned with when caring for this client?

Weight loss

Swelling in the legs

Itching in the upper chest

Abdominal tenderness

Answer and Explanation

The Correct Answer is D

A. Weight loss is a common concern in clients with chronic kidney disease, but it is not the primary concern in this scenario.

B. Swelling in the legs may occur with renal dysfunction but is less concerning than abdominal tenderness, which is indicative of a possible peritoneal infection.

C. Itching in the upper chest may be a symptom of uremia, but abdominal tenderness is more urgent when ruling out a peritoneal infection.

D. Abdominal tenderness is a key sign of peritoneal infection, which requires immediate attention as it can lead to peritonitis.

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Correct Answer is C

Explanation

A. Notify the provider: This is not the first action. The nurse should assess and attempt to resolve the issue before escalating it to the provider.

B. Irrigate the catheter: This may be required if the catheter remains obstructed, but the nurse should first assess for and address more straightforward causes like kinks.

C. Check the catheter for kinks: This is the first step because a kink or simple obstruction in the catheter tubing is a common cause of inadequate drainage. Addressing this can resolve the issue without additional interventions.

D. Adjust the rate of the bladder irrigant: The rate of irrigation is essential to prevent clots but should not be adjusted without addressing the immediate issue of no output.

A. Add the amount of bladder irrigation to the total output B. Notify the surgeon if the urine is bright red an appearance or has large clots C. Use sterile technique when preparing the irrigation solution. D. Contact the surgeon if the client reports a continual need to void. E. Ensure the drainage tubing is patent and without obstruction.

Correct Answer is ["A","B","E"]

Explanation

A. The amount of irrigation fluid used must be added to the total output to accurately calculate fluid balance.

B. Bright red urine or large clots may indicate bleeding, which should be reported to the surgeon immediately.

C. Irrigation solution preparation does not require sterile technique; clean technique is sufficient for this task.

D. A continual need to void could be a normal post-op symptom, but if it persists or is severe, it should be investigated.

E. Ensuring the drainage tubing is patent and unobstructed is essential for proper urine flow and preventing complications.

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A client has been admitted into the Dialysis unit to rule out a peritoneal infection. Which of the following clinical findings should the nurse be MOST concerned with when caring for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past 2 hours. Which actions should the nurse take FIRST?

Correct Answer is C

Explanation

A nurse is caring for a client who is day post-op following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which actions should the nurse take? (Select a that apply)

Correct Answer is ["A","B","E"]

Explanation

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