A nurse is caring for a client who is undergoing peritoneal dialysis. What should the nurse report IMMEDIATELY to the provider?
Clear-colored outflow
Outflow amount exceeds inflow amount
Cloudy opaque colored outflow
Non-purulent outflow
The Correct Answer is C
Choice A reason: Clear-colored outflow is normal and indicates that the dialysis process is functioning correctly.
Choice B reason: Outflow amount exceeding inflow amount may be noted and reported, but it is not an immediate cause for concern unless accompanied by other symptoms.
Choice C reason: Cloudy opaque colored outflow indicates possible peritonitis, an infection of the peritoneum. This is a serious complication that requires immediate medical attention to prevent further complications.
Choice D reason: Non-purulent outflow is not an immediate cause for concern and indicates that there is no infection present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A sore that appears to be healed is not a common indicator of malignancy. It is usually associated with infections or other skin conditions.
Choice B reason: Changes in a mole's shape and size are classic warning signs of melanoma, a type of skin cancer. Moles that become asymmetrical, have irregular borders, vary in color, grow in diameter, or evolve over time need to be evaluated by a healthcare provider.
Choice C reason: Purulent drainage from a mole could indicate an infection, but it is not a typical sign of malignancy.
Choice D reason: Intense pruritus (itching) can be associated with skin conditions, but it is not a definitive indicator of malignancy. While itching can occasionally be a symptom of skin cancer, it is not as specific as changes in mole appearance.
Correct Answer is A
Explanation
Choice A reason: This response acknowledges the client's feelings and validates their experience. It opens the door for the client to express their emotions and share their thoughts. This empathetic approach helps build trust and provides emotional support.
Choice B reason: Telling the client that it takes time to get over the loss of a loved one is a generalized statement that may not provide the support the client needs. It can come across as dismissive and may not encourage further conversation.
Choice C reason: Suggesting that the client try something to take their mind off their troubles can seem dismissive of their grief. It does not address the client's emotional needs or encourage them to talk about their feelings.
Choice D reason: While this response shows some understanding, it does not fully acknowledge the uniqueness of the client's situation. It is important to validate the client's feelings and encourage them to express their emotions.
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