A nurse is caring for a client who has skeletal traction for a fracture of the lower extremity. Which of the following actions should the nurse take?

Choice A reason: Raising the drainage bag above the abdomen reverses gravity flow, stopping dialysate outflow and worsening the issue in peritoneal dialysis. Fluid drains downward naturally, so elevating the bag traps it, potentially causing discomfort or infection risk from stagnation. This action opposes dialysis mechanics, where the bag must stay low, making it contraindicated and detrimental to treatment efficacy.

Choice B reason: High-Fowler’s position (upright) may shift abdominal contents, but it doesn’t directly resolve catheter blockages or flow issues in peritoneal dialysis. It’s used during infusion to aid breathing, not drainage. Without evidence of respiratory distress, this adjustment lacks priority over actions addressing flow directly, like repositioning, rendering it less effective here.

Choice C reason: Measuring dialysate outflow quantifies the flow reduction, identifying if less fluid returns than infused, signaling obstruction or leakage. This data guides interventions, like catheter checks or flushes, ensuring dialysis removes toxins effectively. It’s a critical step in troubleshooting, providing objective evidence of the problem’s scope, essential for maintaining treatment goals.

Choice D reason: Monitoring the access site for drainage detects leaks or infection—common flow rate culprits—as fluid escaping reduces outflow. Peritonitis risk rises with poor site integrity, necessitating early intervention. This action ensures catheter function and patient safety, directly addressing potential causes of the observed decrease, making it vital.

Choice E reason: Repositioning to the other side relieves catheter kinks or omental wrapping, frequent causes of slow flow in peritoneal dialysis. Shifting position adjusts intra-abdominal pressure, freeing the catheter tip to drain properly. This non-invasive fix restores dialysis efficacy, a standard first-line response, directly tackling mechanical flow issues effectively.

Choice A reason: Infusing 0.9% sodium chloride at 150 mL/hr through an arterial line is excessive and dangerous, risking fluid overload or vessel damage. Arterial lines use a slow flush (1-3 mL/hr) to maintain patency, not high-volume infusion. This rate suits IV hydration, not arterial monitoring, making it an incorrect and harmful action for this setup.

Choice B reason: Having the client bear down (Valsalva maneuver) increases intrathoracic pressure, falsely elevating arterial readings, distorting accuracy. Arterial lines provide continuous, real-time pressure via transducers, not manual checks requiring such actions. This technique applies to venous lines or respiratory tests, not arterial monitoring, rendering it inappropriate and misleading here.

Choice C reason: Maintaining the pressure bag at 300 mm Hg ensures a continuous flush (1-3 mL/hr) of saline, preventing clot formation in the arterial line, which could block it. This pressure exceeds arterial systolic values, keeping the system patent and readings accurate. It’s a standard practice, critical for reliable monitoring, making it the correct action in this scenario.

Choice D reason: Aligning the transducer to the radial artery level is incorrect; it should be at the phlebostatic axis (heart level) for accurate pressure readings. Radial alignment overestimates pressure due to gravitational effects, skewing data. Proper calibration at the heart ensures true arterial values, so this action fails to meet monitoring standards.