A nurse is assessing a client following hemodialysis. Which of the following findings indicates dialysis disequilibrium?

A. Apply mitten restraints to prevent the client from disconnecting their tube feeding: Mitten restraints are often used to prevent clients from pulling out tubes or disrupting medical devices. The nurse can apply these restraints as long as they follow the prescribed protocol.

B. Apply soft heel protectors bilaterally while client is in bed: Soft heel protectors are commonly used to prevent pressure ulcers or skin breakdown in immobile clients. This is a standard, non-controversial intervention and does not require verification.

C. Applying a vest restraint daily at bedtime to prevent nighttime wandering is considered a physical restraint used for convenience or punishment, which is a violation of client rights and safety. Restraints should only be used as a last resort when all less restrictive alternatives have failed and for the shortest duration possible.

D. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation: The use of an abduction pillow is common after hip replacement surgery or for patients at risk of hip dislocation. This is an appropriate intervention.

A. Place a mask on the client during the procedure: A mask should be placed on the client to reduce the risk of infection during the dressing change. Peritoneal dialysis involves accessing the peritoneal cavity, and maintaining a sterile environment is crucial to prevent contamination.

B. Cleanse the catheter site using a side-to-side motion: The catheter site should be cleansed using a circular motion starting from the site of insertion and moving outward. This helps avoid introducing bacteria into the insertion site. Side-to-side motion may push bacteria into the area.

C. Tape down the corners of the dressing: While securing the dressing is important, taping the corners may not provide the optimal seal and could risk introducing contaminants. The dressing should be secured properly, but not necessarily with just tape at the corners.

D. Secure an occlusive dressing over the gauze pads: An occlusive dressing over gauze pads is not ideal for peritoneal dialysis catheters. A sterile, breathable dressing is recommended to allow for proper airflow and prevent moisture accumulation, which can promote infection.