A nurse is providing peritoneal dialysis to a child and observes there is minimal dialysate outflow at the end of the outflow time. Which of the following actions should the nurse take?

Increase oral fluid intake.

Increase the dwell time during the next dialysis infusion.

Instruct the child to change position.

Assess for a bruit at the site of the peritoneal catheter.

Answer and Explanation

The Correct Answer is C

A.   Increasing oral fluid intake would not necessarily improve dialysate outflow. This could worsen the issue if the problem is related to fluid overload.
B.   Increasing dwell time might allow more time for fluid and waste removal, but it's not the most appropriate action in this case. The primary concern is the lack of outflow, which suggests a potential obstruction or other issue.
C.   Changing the child's position can help to reposition the catheter and improve drainage. This is a reasonable action to try.
D.   A bruit indicates increased blood flow to the area. While it's important to assess for this, it's not the most immediate action to take.

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Correct Answer is A

Explanation

A. The doll's eye reflex, or oculocephalic reflex, is a normal reflex in infants up to about 2 months of age. It involves the eyes moving in the opposite direction of head movement. By 4 months of age, this reflex

typically disappears as the infant’s voluntary eye movements become more developed. Therefore, if the
B. By 4 months of age, it is normal for an infant to show significant reduction in head lag when pulled to a sitting position. Ideally, the infant should be able to hold their head up with minimal lag.
C. The Babinski reflex is a normal reflex in infants, where the toes fan out when the sole of the foot is stroked. This reflex is expected to be positive in infants up to about 12-24 months of age. By 4 months, a positive Babinski reflex is still normal and does not indicate a problem.
D. Infants typically start producing tears around 2-3 months of age. By 4 months, the presence of tears when crying is a normal developmental milestone and indicates healthy lacrimal gland function. Therefore, this finding is normal and does not need to be reported to the provider.

A. Witness the adolescent's signature on the informed consent form. B. Notify the provider who is scheduled to perform the procedure. C. Request assistance from the anesthesiologist to clarify the misunderstanding. D. Explain the procedure to the adolescent and their guardian.

Correct Answer is B

Explanation

A. While witnessing the signature is part of the process, addressing the guardian's lack of understanding is more important at this point.
B. The provider who will perform the procedure is best equipped to explain the medical necessity of the cardiac catheterization to the guardian. They can address the guardian's concerns and ensure informed consent.
C. While the anesthesiologist is part of the care team, they may not be as knowledgeable about the specific reasons for the procedure as the performing provider.
D. Nurses should not provide medical diagnoses or explanations for procedures. This is the role of the healthcare provider.

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A nurse is providing peritoneal dialysis to a child and observes there is minimal dialysate outflow at the end of the outflow time. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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