To prevent the most common serious complication of peritoneal dialysis, it is important for the nurse to:

Reposition the patient frequently and promote deep breathing.

Infuse the dialysate slowly.

Use strict aseptic technique in the dialysis procedures.

Have the patient empty the bowel before the inflow phase.

Answer and Explanation

The Correct Answer is C

Choice A reason: Repositioning the patient frequently and promoting deep breathing are important interventions for various conditions, particularly for preventing atelectasis and respiratory complications. However, they are not directly related to preventing the most common serious complication of peritoneal dialysis, which is peritonitis.

Choice B reason: Infusing the dialysate slowly can help manage discomfort and ensure proper fluid exchange during peritoneal dialysis. However, it does not address the most serious complication, which is infection.

Choice C reason: Using strict aseptic technique in dialysis procedures is crucial in preventing peritonitis, the most serious and common complication of peritoneal dialysis. Peritonitis is an infection of the peritoneal cavity and can lead to severe complications if not prevented. Adhering to aseptic techniques during catheter insertion, connection, disconnection, and any other procedure involving the dialysis system is essential to reduce the risk of infection.

Choice D reason: Having the patient empty the bowel before the inflow phase can help ensure adequate space in the peritoneal cavity for the dialysate and prevent discomfort. However, this action does not directly prevent the serious complication of peritonitis.

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Correct Answer is C,D,A,B

Explanation

Choice A reason: Assessing the client's respiratory status is the top priority action. This ensures that any immediate issues with breathing or oxygenation are identified and managed promptly. Respiratory status can quickly deteriorate in patients with heart failure, and addressing this first can be life-saving.

Choice B reason: Drawing blood to assess the patient's serum electrolytes is important to determine any imbalances that need immediate correction. Electrolyte levels can affect heart function and overall stability, so understanding the patient's current status helps guide further treatment.

Choice C reason: Administering the prescribed intravenous furosemide (Lasix) is critical for managing fluid overload in heart failure. Furosemide helps reduce fluid retention and alleviate symptoms such as pulmonary edema, which can improve respiratory status and overall comfort.

Choice D reason: Asking the patient about an advanced directive is important for understanding their wishes and planning care accordingly. However, it is not an immediate priority compared to stabilizing the patient's respiratory status and addressing urgent medical needs.

A. Patient with urine output of 40 mL/hr for the last hour. B. Patient with a blood pressure change of 128/74 to 110/88 mmHg. C. Patient with oxygen saturation maintained at 94%. D. Patient with a pulse change of 100 to 88 beats/min.

Correct Answer is B

Explanation

Choice A reason: A urine output of 40 mL/hr is within the acceptable range, as normal urine output is typically around 30-50 mL/hr. While it should be monitored, it does not indicate an immediate life-threatening issue requiring urgent assessment.

Choice B reason: A blood pressure change from 128/74 to 110/88 mmHg may indicate potential hemodynamic instability. Although the systolic blood pressure has decreased, the diastolic pressure has increased, which can be concerning. This patient may be at risk for developing more significant blood pressure changes or other complications, making this situation the highest priority for assessment.

Choice C reason: An oxygen saturation level of 94% is generally considered acceptable. While it is on the lower end of the normal range, it does not indicate an immediate life-threatening condition. Continuous monitoring is important, but it is not the most urgent situation compared to the blood pressure change.

Choice D reason: A pulse change from 100 to 88 beats/min represents a decrease in heart rate but remains within the normal range for adult heart rate (60-100 beats/min). While this change should be noted and monitored, it is not as urgent as the blood pressure change that may indicate hemodynamic instability.

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To prevent the most common serious complication of peritoneal dialysis, it is important for the nurse to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C,D,A,B

Explanation

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Correct Answer is B

Explanation

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