A client on peritoneal dialysis is experiencing cloudy dialysate drainage. Which of the following actions should the nurse take first?
Document the finding and continue monitoring the client.
Administer an antibiotic medication.
Increase the dialysis exchange frequency.
Check the client's vital signs and assess for abdominal pain.
The Correct Answer is D
A) This statement is incorrect. Cloudy dialysate drainage may indicate infection or peritonitis, and the nurse should not simply document the finding and continue monitoring without further assessment.
B) This statement is incorrect. Administering an antibiotic medication without a definitive diagnosis is not appropriate. The nurse should assess the client further to determine the cause of the cloudy drainage.
C) This statement is incorrect. Increasing the dialysis exchange frequency would not address the issue of cloudy dialysate drainage and may not be indicated without a proper assessment.
D) This statement is correct. Cloudy dialysate drainage may indicate infection or peritonitis. The nurse should check the client's vital signs and assess for signs of abdominal pain or tenderness, as this requires immediate evaluation.
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Related Questions
Correct Answer is B
Explanation
A. Incorrect. Administering a prescribed analgesic may be necessary, but it is not the priority when the client is experiencing sudden chest pain and dyspnea.
B. Correct. The sudden onset of chest pain and dyspnea can be indicative of potential complications, such as dialysis-related hypotension, cardiac issues, or fluid overload. Assessing the client's blood pressure and heart rate is the priority to identify any acute changes or abnormalities.
C. Incorrect. Monitoring the client's weight is important to assess fluid status, but it is not the immediate priority when the client presents with acute chest pain and dyspnea.
D. Incorrect. Placing the client in a semi-Fowler's position may be appropriate for respiratory distress, but the nurse should first assess the client's vital signs and overall condition before implementing positioning changes.
Correct Answer is B
Explanation
A. Increase the dialysis session duration: Extending the session may help reduce fluid shifts over time, but it is not an immediate intervention to relieve acute muscle cramps during dialysis.
B. Increase the dialysate solution temperature: Warming the dialysate can improve muscle perfusion and reduce the incidence of cramping during dialysis. It helps minimize vasoconstriction and discomfort.
C. Decrease the dialysate solution flow rate: This is not typically used to treat muscle cramps. Flow rate adjustments affect solute clearance and may not alleviate cramping.
D. Administer an anticoagulant medication: Anticoagulants are used to prevent clotting in the dialysis circuit and do not treat or prevent muscle cramps.
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