A nurse is providing care to a client who has peritonitis. Which of the following conditions is the highest priority for
the nurse to monitor?
Heart atack
Diabetes
Respiratory failure
Sepsis
The Correct Answer is D
Choice A reason: While a heart atack is a serious condition, it is not directly related to peritonitis. Peritonitis can lead to systemic infection, which may indirectly affect the heart, but it is not the primary concern in the immediate care of peritonitis.
Choice B reason: Diabetes is a chronic condition that requires ongoing management. However, it is not the most immediate threat when a client is diagnosed with peritonitis. The nurse should continue to monitor blood glucose levels as part of routine care.
Choice C reason: Respiratory failure can be a complication of peritonitis if the infection spreads and affects other systems. However, the primary concern with peritonitis is the potential for the infection to lead to sepsis.
Choice D reason: Sepsis is a life-threatening condition that can occur as a complication of peritonitis. It happens when the body's response to infection causes injury to its own tissues and organs. Monitoring for signs of sepsis is crucial because early intervention can be lifesaving.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: Headache and restlessness can be signs of a seizure or neurological disturbance, which phenytoin is used to treat. Phenytoin is an anticonvulsant medication that helps control seizures by stabilizing neuronal membranes and reducing excitability.
Choice B rationale: Decreased blood pressure and rapid pulse are not indications for phenytoin administration. These symptoms may suggest hypotension or cardiovascular issues, which require different interventions such as fluid resuscitation or vasopressors.
Choice C rationale: Muscle cramps and chest heaviness are not treated with phenytoin. These symptoms could indicate electrolyte imbalances or cardiac issues, which need specific treatments like electrolyte replacement or cardiac monitoring.
Choice D rationale: Pain and tingling at the access site are not indications for phenytoin administration. These symptoms may suggest local irritation or infection at the dialysis access site, requiring appropriate wound care or antibiotics.
Correct Answer is C
Explanation
Choice A reason: The output solution is typically the same or slightly less than the input solution due to fluid removal during dialysis.
Choice B reason: The fluid from the abdomen should be clear or slightly yellow; any other color may indicate infection or bleeding.
Choice C reason: Using a microwave to warm the solution is not recommended as it can unevenly heat the solution and damage its composition.
Choice D reason: While sterile precautions are taken, there is still a risk of infection with any catheter.
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