A nurse is caring for a group of clients on a medical unit. For which of the following clients should the nurse intervene immediately?

A client who had an appendectomy and has a urine output of 260 mL over 8 hr

A client who is immobile and has had an episode of urinary incontinence

A client who has COPD and an oxygen saturation of 99%

A client who has a concussion and has developed aphasia

Answer and Explanation

The Correct Answer is D

A. A client who had an appendectomy and has a urine output of 260 mL over 8 hr: A urine output of 260 mL over 8 hours is average (around 32.5 mL/hr), and it does not require immediate intervention. It is important to monitor, but there is no acute concern at this time.

B. A client who is immobile and has had an episode of urinary incontinence: While urinary incontinence can lead to skin breakdown and other issues, it is not immediately life-threatening. The nurse should address it with appropriate interventions, but it is not urgent.

C. A client who has COPD and an oxygen saturation of 99%: An oxygen saturation of 99% in a client with COPD is within normal limits. This indicates that the client’s respiratory status is stable and does not require immediate intervention.

D. A client who has a concussion and has developed aphasia: Aphasia after a concussion can indicate a serious complication, such as increased intracranial pressure or a brain injury. This requires immediate intervention to assess the severity of the condition and prevent further neurological damage.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Place a mask on the client during the procedure: A mask should be placed on the client to reduce the risk of infection during the dressing change. Peritoneal dialysis involves accessing the peritoneal cavity, and maintaining a sterile environment is crucial to prevent contamination.

B. Cleanse the catheter site using a side-to-side motion: The catheter site should be cleansed using a circular motion starting from the site of insertion and moving outward. This helps avoid introducing bacteria into the insertion site. Side-to-side motion may push bacteria into the area.

C. Tape down the corners of the dressing: While securing the dressing is important, taping the corners may not provide the optimal seal and could risk introducing contaminants. The dressing should be secured properly, but not necessarily with just tape at the corners.

D. Secure an occlusive dressing over the gauze pads: An occlusive dressing over gauze pads is not ideal for peritoneal dialysis catheters. A sterile, breathable dressing is recommended to allow for proper airflow and prevent moisture accumulation, which can promote infection.

A. Raise the drainage bag above the level of the client's abdomen. B. Elevate the client to the high-Fowler's position. C. Measure the amount of the dialysate outflow. D. Monitor the access site for drainage. E. Reposition the client onto the other side.

Correct Answer is ["B","C","E"]

Explanation

A. Raise the drainage bag above the level of the client's abdomen: This would decrease the flow rate of the dialysate. To facilitate proper drainage, the drainage bag should be kept lower than the level of the client's abdomen to allow gravity to assist in the outflow of dialysate.

B. Elevate the client to the high-Fowler's position: Elevating the client to a high-Fowler's position (sitting up at a 90-degree angle) can help improve the flow of dialysate by using gravity to promote better drainage, especially if there is fluid retention in the abdomen.

C. Measure the amount of the dialysate outflow: It's important to measure the dialysate outflow to assess the effectiveness of the dialysis and ensure that the prescribed amount of fluid is being drained. A decrease in outflow could indicate a blockage, kinked catheter, or other complications.

D. Monitor the access site for drainage: While monitoring the access site is important for assessing infection or leakage, a decrease in the dialysate flow rate is not related to drainage from the access site. Therefore, this is not a priority for addressing the decrease in flow rate.

E. Reposition the client onto the other side: Repositioning the client can help resolve any issues with the catheter position, which may be causing the decrease in flow. Moving the client can help improve drainage if the catheter is obstructed or kinked.

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A nurse is caring for a group of clients on a medical unit. For which of the following clients should the nurse intervene immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is changing the dressing for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving peritoneal dialysis and notes a decrease in the dialysate flow rate. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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