When providing care for a client receiving peritoneal dialysis. While draining the dialysate the nurse notices that the efluent is cloudy. Which intervention is most important for the nurse to carry out at this moment?

Prepare the client for emergency surgery.

Send a specimen for culture and sensitivity.

Clamp the catheter and call the provider.

Irrigate the peritoneal catheter with sterile saline

Answer and Explanation

The Correct Answer is B

Choice A rationale: Cloudy efluent doesn't necessarily indicate a need for emergency surgery unless accompanied by severe symptoms.

Choice B rationale: Cloudy efluent may indicate infection, so obtaining a culture and sensitivity test is crucial for appropriate treatment.

Choice C rationale: This step might be necessary if the efluent suggests infection, but sending a specimen for testing is the immediate priority.

Choice D rationale: This action isn't the first step; investigating the cause of cloudiness through testing is essential.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale: A/V fistula assessment is not concerning because a positive bruit and thrill indicate adequate blood flow through the fistula. A dry dressing with scant amount of blood is expected after hemodialysis.

Choice B rationale: The client's low blood pressure could indicate hypotension, which can be critical, especially after hemodialysis. It may contribute to the client's reported dizziness and fatigue.

Choice C rationale: The client’s pulse is irregular which may indicate cardiac arrhythmia. Choice D rationale: Anuria, the absence of urine output, is a significant concern. It could indicate kidney dysfunction or inadequate clearance of waste products, which may have implications following hemodialysis.

Choice E rationale: Oxygen saturation at 92% is relatively low. While the client is alert and oriented, a low oxygen saturation level may indicate potential respiratory compromise or inadequate oxygenation.

Choice F rationale: Temperature is not concerning because it is within normal range.

Choice G rationale: Neurological assessment is not concerning because the client is alert and oriented. The dizziness is likely related to the hypotension and will resolve once the blood pressure is stabilized.

A. Right lower quadrant abdominal pain B. Fever C. Nausea and vomiting D. Unable to pass stool E. distended abdomen

Correct Answer is ["C","D","E"]

Explanation

Choice A rationale: Small bowel obstructions typically present with diffuse, crampy abdominal pain rather than localized pain in the right lower quadrant.

Choice B rationale: While fever can be present in some cases, it's not a consistent finding with small bowel obstruction unless there's perforation.

Choice C rationale: Common symptoms of small bowel obstruction due to the buildup of contents proximal to the obstruction.

Choice D rationale: A key feature of small bowel obstruction due to the blockage preventing normal bowel movements.

Choice E rationale: Accumulation of gas and fluid above the obstruction causes abdominal distention.

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When providing care for a client receiving peritoneal dialysis. While draining the dialysate the nurse notices that the efluent is cloudy. Which intervention is most important for the nurse to carry out at this moment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 67-year-old client in the medical-surgical unit following hemodialysis. The nurse reviews the nursing note, vital signs, assessment, and medical history Which clinical data is most concerning to the nurse? Select all that apply

Correct Answer is ["B","C","D","E"]

Explanation

Correct Answer is ["C","D","E"]

Explanation

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