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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hypotension (low blood pressure) is not a typical manifestation of the oliguric phase of acute kidney injury. In fact, during this phase, patients are more likely to experience hypertension due to fluid overload.
Choice B reason: Hyperglycemia is not directly related to acute kidney injury. While blood sugar levels can be affected by various factors, they are not a specific manifestation of this condition.
Choice C reason: Weight loss is unlikely in the oliguric phase of acute kidney injury. Instead, patients might experience weight gain due to fluid retention.
Choice D reason: Pulmonary edema is a common manifestation in the oliguric phase of acute kidney injury. This phase is characterized by decreased urine output, leading to fluid overload and subsequent complications such as pulmonary edema, where fluid accumulates in the lungs.
Correct Answer is C
Explanation
Choice A reason: The statement "I can change who serves as my health care proxy at any time" is correct. A client can modify or revoke their health care proxy designation as long as they are mentally competent.
Choice B reason: The statement "The health care proxy does not go into effect until I am incapable of making decisions" is accurate. The health care proxy is activated when the client is unable to make their own medical decisions.
Choice C reason: The statement "I have to choose a family member as my health proxy" indicates a need for clarification. A client is not required to choose a family member as their health care proxy; they can select any trusted individual to act in this capacity.
Choice D reason: The statement "My health care proxy can make decisions on my behalf if I am unable to do so" is correct. The purpose of a health care proxy is to appoint someone to make medical decisions when the client is incapacitated.
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