A nurse is caring for a client with chronic renal failure who is receiving peritoneal dialysis. The client reports cloudy dialysate effluent during an exchange. What should the nurse do first?
Assess the client's vital signs and blood pressure.
Obtain a sample of the cloudy effluent for testing.
Instruct the client to stop the exchange immediately.
Provide the client with an analgesic for pain relief.
The Correct Answer is B
A. Incorrect. While assessing vital signs and blood pressure is important, it is not the first action when the client reports cloudy dialysate effluent during an exchange.
B. Correct. Cloudy dialysate effluent may indicate peritonitis, an infection of the peritoneal cavity. Obtaining a sample of the effluent for testing is the first action to determine if an infection is present and requires immediate treatment.
C. Incorrect. Instructing the client to stop the exchange immediately may be necessary if there are signs of infection or other complications, but obtaining a sample of the effluent should be done first to determine the cause.
D. Incorrect. Providing the client with an analgesic is not the priority when the client reports cloudy dialysate effluent; the focus is on identifying the cause of the cloudiness.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Peripheral neuropathy, characterized by tingling sensations or "pins and needles" in the hands and feet, is a common neurological complication of chronic renal failure. Uremic toxins build up in the blood when the kidneys are unable to adequately filter waste products, leading to nerve damage and peripheral neuropathy.
B. Incorrect. Increased blood flow to the extremities is not typically associated with the "pins and needles" sensation described by the client.
C. Incorrect. Adequate nerve conduction related to calcium levels would not cause the "pins and needles" sensation; instead, disturbances in calcium levels can lead to other neurological symptoms.
D. Incorrect. Hypokalemia, or low potassium levels, can cause muscle weakness or cramps but is not typically associated with peripheral neuropathy.
Correct Answer is B
Explanation
A. Incorrect. Reducing protein intake can lead to calcium loss and bone fractures in clients with chronic renal failure, as it may affect
bone health.
B. Correct. Limiting protein intake is a common dietary recommendation for clients with chronic renal failure to reduce the workload on the kidneys and slow the progression of kidney damage. Protein metabolism produces waste products that the kidneys must filter and excrete, and reducing protein intake can help alleviate this burden on the already compromised kidneys.
C. Incorrect. Decreasing protein intake may not necessarily improve appetite or overall nutritional status, as protein is essential for maintaining body functions and tissue repair.
D. Incorrect. While reducing protein intake can result in fewer waste products being generated, the primary reason for limiting protein intake in chronic renal failure is to reduce the strain on the kidneys, not solely to decrease waste production.
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