A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client's spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?
Take the client to the emergency department (ED)
Apply the client's home oxygen
Ensure that the client avoids salt intake for the rest of the day
Check for a thrill and bruit at the client's dialysis access site
The Correct Answer is A
Choice A reason: Taking the client to the emergency department is crucial because missing a dialysis session can lead to severe complications such as fluid overload, high potassium levels, and other electrolyte imbalances. These conditions can be life-threatening and require immediate medical attention to stabilize the client.
Choice B reason: Applying home oxygen is not the most critical intervention in this scenario. While oxygen therapy might be necessary in some cases, it does not address the immediate risk of complications arising from missed dialysis.
Choice C reason: Ensuring that the client avoids salt intake for the rest of the day is important for managing fluid balance, but it is not the most urgent action needed in this situation. The client's lethargy and difficulty arousing indicate a more serious underlying issue that requires immediate medical evaluation.
Choice D reason: Checking for a thrill and bruit at the client's dialysis access site is important for assessing the patency of the access site, but it is not the most critical action in this scenario. The immediate concern is the client's lethargy and potential complications from missed dialysis, which necessitate emergency medical care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: An exit site infection can occur around the catheter insertion site, leading to redness, tenderness, and drainage. While this is a concerning issue that needs to be addressed, the more significant complication to prevent is peritonitis, which can result from an exit site infection if it spreads.
Choice B reason: Peritonitis is a serious and potentially life-threatening infection of the peritoneal cavity. In clients on peritoneal dialysis, signs such as redness, tenderness, and drainage around the catheter site are alarming indicators that could lead to peritonitis if not promptly treated. Peritonitis can cause severe abdominal pain, fever, and cloudy dialysis fluid, and requires immediate medical intervention to prevent complications.
Choice C reason: Outflow obstruction is a complication where the peritoneal dialysis fluid does not drain properly. This can be caused by a number of issues including catheter malposition or blockages, but it is not directly related to the symptoms of redness, tenderness, and drainage at the catheter site. Outflow obstruction is important to monitor but does not represent the immediate risk that peritonitis does.
Choice D reason: Atelectasis refers to the collapse of a part or all of a lung, often due to blockage of the air passages. This is not related to the symptoms around the peritoneal dialysis catheter site. While respiratory issues must be monitored, the primary concern here is the potential for peritoneal infection.
Correct Answer is ["56"]
Explanation
Step-by-Step Calculation:
Step 1: Convert liters to milliliters (mL) 2 liters × 1000 mL per liter = 2000 mL
Step 2: Calculate the total number of drops to be infused 2000 mL × 20 gtt per mL = 40000 gtt
Step 3: Convert hours to minutes 12 hours × 60 minutes per hour = 720 minutes
Step 4: Calculate the drops per minute 40000 gtt ÷ 720 minutes = 55.56
Step 5: Round to the nearest whole number 56 gtt/min
Answer: 56 gtt/min
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