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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?

A.

Place a mask on the client during the procedure

B.

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

C.

Tape down the corners of the dressing

D.

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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Related Questions

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

Explanation

Rationale for Correct Choices

  • Blood glucose: The client’s blood glucose decreased from 250 mg/dL to 140 mg/dL, indicating a positive response to diabetes management through medication and dietary adherence. This is a key marker of metabolic control in diabetes.
  • Urinary frequency: Two weeks ago, the client reported "frequent urination" (polyuria), which is a classic symptom of uncontrolled hyperglycemia. Today, this symptom is not reported, and given the improvement in blood glucose, it's highly probable that the polyuria has resolved or significantly decreased.

Rationale for Incorrect Choices

  • Temperature: The client’s temperature increased from 38.3°C to 39.0°C, suggesting a worsening or persistent infection. An increasing fever is a negative trend and does not indicate improvement.
  • WBC: The WBC count rose from 9,500/mm³ to 11,200/mm³, exceeding the normal upper limit. This may reflect an active or worsening infection, especially in the context of a draining foot wound and elevated temperature.
  • Heart rate: The heart rate remains elevated at 106/min (tachycardia) compared to the previous 104/min. Persistent tachycardia can be a sign of systemic infection or dehydration and is not a sign of clinical improvement.
  • Blood pressure: The blood pressure decreased from 98/74 mm Hg to 90/68 mm Hg, which may suggest worsening hemodynamic status and possible sepsis. Hypotension is not an indicator of improvement.

Correct Answer is C

Explanation

A. Excessive urinary output: In syndrome of inappropriate antidiuretic hormone (SIADH), there is decreased urinary output, not excessive output. The body retains water due to increased antidiuretic hormone (ADH), leading to fluid retention.

B. Elevated sodium level: Due to excessive water retention and dilution of electrolytes, clients with SIADH typically experience hyponatremia (decreased sodium level), not an elevated sodium level. The retained water dilutes the body's sodium concentration.

C. Bounding peripheral pulses: Bounding peripheral pulses are expected in SIADH due to fluid overload, as the body retains excessive water. This leads to increased blood volume and can cause the peripheral pulses to feel strong or "bounding."

D. Hyperactive deep tendon reflexes: Hyperactive deep tendon reflexes are typically associated with conditions such as hypercalcemia or hyperthyroidism, not SIADH. SIADH is more likely to cause muscle weakness and fatigue due to hyponatremia.

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