The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100 mL less than the input flow. Which actions should the nurse implement first?

Irrigate the dialysis catheter.

Check the client's blood pressure and serum bicarbonate.

Continue to monitor intake and output with next exchange.

Change the client's position.

Answer and Explanation

The Correct Answer is D

A. Irrigating the dialysis catheter is an invasive intervention and is not the first-line action. It also typically requires a provider’s prescription or specific protocol due to the risk of infection and peritoneal injury. The initial response should focus on simple, noninvasive measures to restore flow.

B. Checking blood pressure and serum bicarbonate may be useful in assessing overall fluid and metabolic status; however, these actions do not directly address the immediate issue of decreased outflow during CAPD. This makes it a secondary assessment rather than the priority first action.

C. Continuing to monitor intake and output without intervention delays addressing a potential problem. A discrepancy between inflow and outflow suggests impaired drainage, which should be corrected promptly to prevent complications such as fluid retention or infection. Passive monitoring is not appropriate as a first response.

D. TA common cause of reduced outflow in CAPD is catheter obstruction due to positioning, such as the catheter resting against the bowel or omentum. Repositioning the client (e.g., turning side to side, sitting upright) is a simple, noninvasive, and immediate intervention that often restores proper drainage. It is always the first step before progressing to more invasive measures.

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Correct Answer is C

Explanation

A. A client with a subdural hematoma experiencing a significant change in blood pressure requires close monitoring and potentially urgent intervention. This patient’s condition is unstable and requires the assessment and clinical judgment of an RN, not a PN.

B. A client in myxedema coma with worsening hypotension is critically ill. The PN may assist with basic care, but managing hemodynamic instability in a life-threatening endocrine emergency requires RN-level assessment and intervention.

C. This is the most appropriate assignment for the PN. The client has viral meningitis with a mild temperature increase, indicating a relatively stable condition that requires monitoring and routine care rather than immediate complex interventions. The PN can safely perform tasks such as vital signs monitoring, basic neurological checks, and reporting changes to the RN.

D. A client with diabetic ketoacidosis (DKA) whose Glasgow Coma Scale score has decreased from 10 to 7 is showing signs of neurological deterioration and severe metabolic instability. This is an urgent, high-risk situation requiring RN-level assessment, critical thinking, and potentially rapid interventions such as fluid resuscitation, electrolyte replacement, and airway management. The PN should not be assigned this patient.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"A"}

Explanation

Rationale for correct choices:

Esophageal stricture: Chronic acid exposure can lead to scarring and narrowing of the esophagus, causing dysphagia.
Barrett's esophagus: Prolonged GERD can cause metaplasia of esophageal cells, increasing the risk of esophageal cancer.
Reflux esophagitis: Ongoing acid reflux causes inflammation and damage to the esophageal lining.

Rationale for incorrect choices:

Hiatal hernia: While a hiatal hernia can contribute to GERD, it is a structural condition that precedes reflux rather than a complication resulting from untreated GERD.

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The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100 mL less than the input flow. Which actions should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

Correct Answer is C

Explanation

Drag from Word Choices to complete the sentence. The nurse knows that, if left untreated, the client's condition could progress to developingdropdown,dropdownanddropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"A"}

Explanation

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