A nurse in a mental health facility is caring for a client.

Exhibits

For each potential nursing action, click to specify if the potential action is anticipated, nonessential, or contraindicated for the client.

A. Peritonitis is an infection of the peritoneum, typically associated with peritoneal dialysis, not hemodialysis. Symptoms would usually include fever, abdominal pain, and cloudy dialysate rather than headache, nausea, and restlessness.
B. Air embolism is a rare but serious complication of hemodialysis caused by air entering the bloodstream. Symptoms would include chest pain, hypotension, and shortness of breath, not headache, nausea, and restlessness.
C. Dialysis disequilibrium is the correct answer. This complication occurs when there is a rapid change in blood chemistry during hemodialysis, particularly in those with acute kidney injury or chronic kidney disease. The symptoms—headache, nausea, restlessness, confusion, and even seizures—are a result of the rapid reduction in blood urea levels and the shift of fluid and electrolytes in the body.
D. Septicemia refers to a blood infection and is associated with symptoms like fever, chills, hypotension, and tachycardia. While it is a potential complication of dialysis, the described symptoms of headache, nausea, and restlessness are more consistent with dialysis disequilibrium.

A. "You should anticipate pain the first week during the inflow of dialysate." This is correct. It is common for clients performing peritoneal dialysis to experience some discomfort during the inflow of dialysate, especially during the first week as they adjust to the procedure. The discomfort is typically mild and temporary, and it can be alleviated by slowing the inflow rate or adjusting the position of the catheter.
B. "You should expect redness at the catheter exit site." This is incorrect. While mild redness may occur occasionally, persistent redness, warmth, swelling, or discharge could indicate an infection at the catheter site. In that case, the client should seek medical advice promptly. The nurse should encourage proper hygiene and care of the catheter site to prevent infection.
C. "You should warm the dialysate in a microwave oven before instillation." This is incorrect. Dialysate should not be warmed in a microwave, as uneven heating could cause injury to the client. Dialysate should be warmed using a specialized heating pad or in a warm water bath to prevent burns or discomfort.
D. "You should avoid foods high in fiber." This is incorrect. There is no need to avoid high-fiber foods unless specifically directed by the healthcare provider. Fiber is generally beneficial for digestive health, but clients on peritoneal dialysis may need to monitor their fluid and diet intake depending on their individual condition.