A nurse is caring for a client on peritoneal dialysis who complains of cloudy drainage from the catheter site. Which of the following actions should the nurse take first?

Administer an antibiotic for potential infection.

Measure the client's vital signs and assess for pain.

Clamp the catheter and notify the healthcare provider.

Obtain a sample of the drainage for culture and sensitivity testing.

Answer and Explanation

The Correct Answer is D

A) This statement is incorrect. While administering an antibiotic may be necessary if peritonitis is confirmed, it should not be done without obtaining a sample for testing first.

B) This statement is incorrect. Measuring vital signs and assessing for pain are essential aspects of client assessment, but they may not provide enough information to determine the cause of the cloudy drainage.

C) This statement is incorrect. Clamping the catheter may be necessary if peritonitis is suspected, but it should not be done without first obtaining a sample of the drainage for testing.

D) This statement is accurate. Cloudy drainage from the catheter site may indicate peritonitis, which is an infection of the peritoneal cavity. Obtaining a sample of the drainage for culture and sensitivity testing can help identify the presence of infection and guide appropriate treatment.

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Correct Answer is C

Explanation

A. Incorrect. Protein intake is essential for maintaining body functions, but clients on dialysis may need to adjust their protein intake based on their individual needs and dialysis prescription.

B. Incorrect. Clients on dialysis may need to limit their sodium intake to manage fluid retention and blood pressure.

C. Correct. Clients on dialysis often need to avoid potassium-rich foods to prevent hyperkalemia, as the kidneys are unable to adequately remove excess potassium from the blood.

D. Incorrect. Clients on dialysis typically need to restrict their phosphorus intake to prevent complications related to high phosphorus levels, such as bone disease and cardiovascular issues.

A. Palpate for a thrill or vibration over the AV fistula site. B. Auscultate for bruits over the radial artery. C. Check for distal pulses in the lower extremities. D. Assess for swelling and tenderness in the neck.

Correct Answer is A

Explanation

A) This statement is accurate. Palpating for a thrill or vibration over the AV fistula site is a critical assessment to ensure proper functioning. A thrill indicates adequate blood flow through the fistula, which is essential for effective hemodialysis.

B) This statement is incorrect. Auscultating for bruits over the radial artery is not related to the AV fistula assessment. The bruit is the sound of blood flow in the fistula, which is best assessed directly over the fistula site.

C) This statement is incorrect. Checking for distal pulses in the lower extremities is not related to the assessment of an AV fistula. The AV fistula is typically created in the upper extremity.

D) This statement is incorrect. Assessing for swelling and tenderness in the neck is not related to the AV fistula assessment. Swelling and tenderness may be related to other issues but are not specific to AV fistula functioning.

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A nurse is caring for a client on peritoneal dialysis who complains of cloudy drainage from the catheter site. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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