A nurse is caring for a client who is undergoing initial peritoneal dialysis. Which of the following should the nurse
report immediately to the provider?
Blood-tinged dialysate outflow
Dialysate leakage during inflow
Report of discomfort during dialysate inflow
Purulent dialysate outflow
The Correct Answer is D
Choice A reason: Blood-tinged dialysate outflow can occur initially due to the surgical procedure and is not typically a cause for immediate concern unless it persists or is accompanied by other symptoms.
Choice B reason: Dialysate leakage during inflow might indicate a problem with the catheter placement or integrity but is not usually an emergency. It should be monitored and reported if it continues.
Choice C reason: Discomfort during dialysate inflow is common, especially in new patients, as they adjust to the sensation of fluid being infused. It should be reported if the discomfort is severe or persistent.
Choice D reason: Purulent dialysate outflow indicates an infection, such as peritonitis, which is a serious complication
of peritoneal dialysis. This requires immediate atention and intervention by the healthcare provider.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Decreasing the IV fluid infusion rate and limiting oral fluid intake may not be appropriate without further assessment, as the client's BUN level is elevated, which could indicate dehydration or renal impairment. The normal range for BUN is typically 7-20 mg/dL.
Choice B reason: Collecting a urine specimen for culture and sensitivity may be necessary if there is a suspicion of infection, but there is no indication of infection based solely on the provided lab values.
Choice C reason: Evaluating urine for amount and specific gravity can help assess the client's hydration status and kidney function, which is pertinent given the elevated BUN level and ongoing nausea and vomiting.
Choice D reason: Continuing routine care may not be appropriate because the BUN level is above the normal range, indicating that further assessment and intervention may be necessary.
Correct Answer is D
Explanation
Choice A reason: While a heart atack is a serious condition, it is not directly related to peritonitis. Peritonitis can lead to systemic infection, which may indirectly affect the heart, but it is not the primary concern in the immediate care of peritonitis.
Choice B reason: Diabetes is a chronic condition that requires ongoing management. However, it is not the most immediate threat when a client is diagnosed with peritonitis. The nurse should continue to monitor blood glucose levels as part of routine care.
Choice C reason: Respiratory failure can be a complication of peritonitis if the infection spreads and affects other systems. However, the primary concern with peritonitis is the potential for the infection to lead to sepsis.
Choice D reason: Sepsis is a life-threatening condition that can occur as a complication of peritonitis. It happens when the body's response to infection causes injury to its own tissues and organs. Monitoring for signs of sepsis is crucial because early intervention can be lifesaving.
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