A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

Listen to the client's bowel sounds.

Initiate cardiac monitoring for the client.

Check the client's hand grasps.

Administer an IV potassium drip.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Listening to the client's bowel sounds should not be implemented. It is important for assessing the gastrointestinal status, but the priority in this situation is to address the potential cardiac complications of hypokalaemia.

Choice B reason:

Initiating cardiac monitoring for the client should be implemented. A serum potassium level of 2.8 mEq/L is significantly low (normal range is typically around 3.5-5.0 mEq/L). Low potassium levels, known as hypokalaemia, can lead to serious cardiac arrhythmias and other complications. Therefore, the nurse should prioritize cardiac monitoring to assess for any potential changes or abnormalities in the client's heart rhythm due to the low potassium levels.

Choice C reason:

Checking the client's hand grasps should not be implemented. It is a test for muscle strength and can be indicative of hypokalaemia, but initiating cardiac monitoring is more critical at this point.

Choice D reason:

Administering an IV potassium drip may be necessary, but initiating cardiac monitoring takes precedence as the first action to ensure the client's heart rhythm is stable before addressing the potassium imbalance.

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Correct Answer is D

Explanation

Choice A Reason:

Generalized abdominal pain - Abdominal pain may be present in peritonitis, but it can develop after other signs and symptoms.

Choice B Reason:

Increased heart rate - An increased heart rate can be a response to infection, but it is not the earliest indicator of peritonitis.

Choice C Reason:

Fever - Fever can also be a sign of infection and peritonitis but may not be the earliest manifestation in all cases.

Choice D Reason:

Cloudy effluent

The earliest indication of peritonitis in a client undergoing peritoneal dialysis is often the presence of cloudy or turbid peritoneal dialysis effluent (fluid). Cloudy effluent can indicate the presence of infection or inflammation in the peritoneal cavity, which is a significant concern in peritoneal dialysis. It's crucial for clients and their partners to recognize this early sign and seek medical attention promptly.

A. Place the client in high-Fowler's position. B. Chill the dialysate before administration C. Hang the drainage bag below the client's abdomen. D. Use clean technique to access the catheter

Correct Answer is A

Explanation

Choice A Reason:

Placing the client in high-Fowler's position is the appropriate action. When administering peritoneal dialysis, the nurse should place the client in a high-Fowler's position. This position helps promote the flow of dialysate into and out of the peritoneal cavity and assists with proper drainage. The high-Fowler's position allows for gravity to aid in the movement of fluid and helps prevent leakage of fluid back into the catheter.

Choice B Reason:

Chilling the dialysate before administration is not necessary and could cause discomfort to the client. Dialysate should be warmed to body temperature before use.

Choice C Reason:

Hanging the drainage bag below the client's abdomen is incorrect. The drainage bag should be positioned below the level of the abdomen to allow for proper drainage by gravity, but it should not be hung too low as this can lead to excessive drainage and dehydration.

Choice D Reason:

Using clean technique to access the catheter is incorrect. Sterile technique is required when accessing the peritoneal dialysis catheter to prevent infection. Peritoneal dialysis involves direct access to the peritoneal cavity, which is considered a sterile body cavity.

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A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?

Correct Answer is D

Explanation

A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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