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 B
Explanation
Choice A reason: While fiber is important in a diet, recommending at least 45 g per day does not specifically address the needs of a patient with diabetic nephropathy.
Choice B reason: Consuming less than 0.8 g/kg of body weight of protein per day is recommended for patients with diabetic nephropathy to reduce the workload on the kidneys.
Choice C reason: Limiting cholesterol intake to 300 mg per day is a general recommendation for heart health but is not specific to diabetic nephropathy dietary management.
Choice D reason: The recommendation to consume less than 45% of total calories from carbohydrates is not specific to diabetic nephropathy, and carbohydrate needs can vary based on individual energy requirements.
Correct Answer is B
Explanation
Choice A reason: Hyperkalemia refers to high potassium levels, which may not directly cause shortness of breath and swelling.
Choice B reason: Hypervolemia, or fluid overload, is likely the cause of the client's symptoms, including shortness of breath, swelling, crackles in the lungs, and elevated blood pressure.
Choice C reason: Hypovolemia, or fluid deficit, would not typically present with swelling and crackles in the lungs.
Choice D reason: Hyponatremia refers to low sodium levels, which may not directly cause the symptoms described.
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