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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Using the arm with the AV fistula for blood pressure measurements can compress the vascular access and compromise blood flow. It is important to avoid using the fistula arm for blood pressure measurements and venipuncture.
B. Incorrect. The AV fistula should not be used for intravenous catheter insertion to prevent potential damage and infection to the access site.
C. Incorrect. Self-cannulation of the AV graft is typically performed by healthcare professionals, and clients should not attempt to self-cannulate their vascular access.
D. Incorrect. If an AV fistula starts bleeding, the client should not apply pressure to the site. Instead, they should immediately elevate the arm and apply pressure to the bleeding site with a clean cloth or bandage while seeking medical attention.
QUESTIONS
Correct Answer is D
Explanation
A) This statement is incorrect. Hypokalemia (low potassium levels) is not an indication for initiating dialysis. In AKI, electrolyte imbalances can occur, but hyperkalemia is more likely due to impaired kidney function.
B) This statement is incorrect. Hyponatremia (low sodium levels) is not a primary indication for initiating dialysis in AKI. It can occur due to fluid shifts, but the primary concern in AKI is the accumulation of waste products like urea, leading to uremia.
C) This statement is incorrect. Hypernatremia (high sodium levels) is not a primary indication for initiating dialysis in AKI. Hypernatremia is rare in AKI and usually occurs when there is a significant loss of free water compared to sodium intake.
D) Uremia, which is characterized by elevated levels of urea and other waste products in the blood, is a critical indication for initiating dialysis in clients with acute kidney injury. Dialysis helps remove these toxic substances from the bloodstream.
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