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

Place a mask on the client during the procedure

Cleanse the catheter site using a side-to-side motion.

Tape down the corners of the dressing

Secure an occlusive dressing over the gauze pads.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is C

Explanation

A. "Plan to void every 6 hours.": Voiding every 6 hours may not be appropriate for clients with stress incontinence. A more individualized schedule based on the client's needs and fluid intake is better. Holding urine for too long could worsen symptoms.

B. "Squeeze your legs together when you feel the urge to void.": This is not effective in managing stress incontinence. Instead, strategies like pelvic muscle exercises (Kegel exercises) can help strengthen the muscles that control urination.

C. "Perform Kegel exercises three times daily.": Kegel exercises help strengthen the pelvic floor muscles, which can reduce stress incontinence by improving bladder control. This is an effective and recommended strategy for managing the condition.

D. "Drink 1 liter of fluids a day.": Restricting fluids can concentrate urine, irritating the bladder and worsening incontinence. It’s generally better to maintain adequate hydration, typically around 2 liters of fluids daily, unless otherwise directed by the healthcare provider.

A. Take an antacid within 30 min after medication administration. B. Increase sources of fiber in the diet. C. Take the medication on an empty stomach. D. Increase intake of milk and dairy products. E. Take the medication with a source of vitamin C.

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

Explanation

Rationale for Correct Choices:

Increase sources of fiber in the diet: Iron supplements, particularly ferrous sulfate, commonly cause constipation. Increasing dietary fiber through fruits, vegetables, and whole grains helps promote bowel regularity and prevent this common side effect.
Take the medication on an empty stomach: Iron is best absorbed in an acidic environment, and taking it on an empty stomach enhances its bioavailability. However, if gastrointestinal upset occurs, it may be taken with a small amount of food, but not with calcium-rich foods.
Take the medication with a source of vitamin C: Vitamin C (ascorbic acid) enhances the absorption of non-heme iron. Consuming iron with a vitamin C-rich beverage or food, like orange juice, increases iron uptake and supports effective treatment of iron deficiency anemia.

Rationale for Incorrect Choices:

Take an antacid within 30 min after medication administration: Antacids reduce stomach acidity, which impairs iron absorption. Iron requires an acidic environment to be absorbed effectively, so antacids should be avoided within 1–2 hours of iron administration.
Increase intake of milk and dairy products: Calcium in dairy products can bind to iron and inhibit its absorption. Iron should not be taken with milk or calcium-rich foods to ensure optimal effectiveness of the supplement.

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

Nursing Test Bank

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