The nurse is teaching a patient about performing peritoneal dialysis (PD) at home. In order to identify the earliest manifestation of peritonitis, what does the nurse instruct the patient to do?
Monitor for abdominal pain.
Monitor temperature before starting PD.
Be aware of feelings of malaise.
Check the effluent for cloudiness.
The Correct Answer is D
Rationale:
A. While abdominal pain may occur with peritonitis, it is a later sign that appears after infection has already developed. The goal is to detect peritonitis at its earliest stage to prevent complications.
B. A fever may occur as peritonitis progresses, but it is not an early indicator. Relying solely on temperature changes may delay recognition of the infection.
C. General malaise is a nonspecific symptom that can occur with many conditions. It does not provide an early or definitive indication of peritonitis.
D. The earliest and most reliable sign of peritonitis in clients receiving peritoneal dialysis is cloudy or opaque dialysate effluent. The cloudiness results from the presence of white blood cells and bacteria in the dialysate, signaling infection in the peritoneal cavity. Prompt reporting and treatment can prevent severe complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Measuring and recording intake and output (I&O) is an appropriate task to delegate to assistive personnel (AP) because it involves collecting objective data and does not require nursing judgment, critical thinking, or clinical decision-making. The nurse remains responsible for interpreting the data, but the task itself falls within the AP’s role.
B. Evaluating pain relief after medication administration requires assessment and nursing judgment, which are RN responsibilities and cannot be delegated to an AP.
C. Wound irrigation involves a sterile or clean technique and assessment of the wound, which requires nursing skill and judgment. This task should be performed by a licensed nurse (RN or LPN).
D. Client teaching, including education about low-sodium foods, requires knowledge of pathophysiology, diet therapy, and evaluation of understanding, which are RN responsibilities and cannot be delegated.
Correct Answer is D
Explanation
Rationale:
A. Checking distal pulses in the left arm is a safe and appropriate nursing action. It helps assess for adequate circulation beyond the AV fistula site and ensures that the vascular access has not compromised blood flow to the distal extremity.
B. Using the right arm for a blood pressure reading is appropriate and safe. Blood pressure measurements, venipunctures, or IV insertions should never be done on the arm with the AV fistula to avoid causing clot formation, vessel damage, or access loss.
C. Palpating the access site for a bruit or thrill is an important routine assessment to verify the patency and proper functioning of the fistula. The presence of a thrill (vibration) and bruit (swishing sound) indicates adequate blood flow through the access.
D. Administering intravenous fluids through the AV fistula is unsafe and contraindicated. The AV fistula must be used only for hemodialysis by trained personnel. Using it for IV fluids or medications increases the risk of infection, thrombosis, or permanent damage to the access site, which could compromise future dialysis treatments.
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