A client diagnosed with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the client’s abdomen is increasing in girth. What is the nurse’s most appropriate action?

Advance the catheter 2 to 4 cm further into the peritoneal cavity

Infuse 50 mL of additional dialysate

Aspirate from the catheter using a 60-mL syringe

Reposition the client to facilitate drainage

Answer and Explanation

The Correct Answer is D

Choice A reason: Advancing the catheter further risks perforation or malposition, potentially damaging peritoneal tissues or organs. Slow drainage is often due to positional obstruction or constipation, not catheter depth. This invasive action requires medical orders and imaging confirmation, making it inappropriate as a first step in addressing slow drainage.

Choice B reason: Infusing additional dialysate worsens abdominal distension and does not address slow drainage. It may increase intra-abdominal pressure, causing discomfort or complications like hernia. The issue is outflow obstruction, not insufficient dialysate, so adding more fluid is counterproductive and could exacerbate the client’s condition.

Choice C reason: Aspirating with a syringe is not standard practice and risks introducing infection or damaging the catheter. It does not address underlying causes like positional obstruction or fibrin clots. Medical evaluation or specialized interventions like heparin instillation are needed for persistent drainage issues, making this action inappropriate.

Choice D reason: Repositioning the client facilitates drainage by relieving positional obstructions, such as catheter kinking or omental wrapping, common in peritoneal dialysis. Changing positions (e.g., side-lying or sitting) promotes gravity-assisted flow, reducing abdominal girth and improving exchange efficiency. This non-invasive action is the safest and most effective initial step.

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Correct Answer is D

Explanation

Choice A reason: Left-sided flank pain may suggest kidney stones or infection but is not specific to AKI. Pain can occur in various conditions, including pyelonephritis or ureteral obstruction, and does not directly indicate reduced glomerular filtration or oliguria, which are hallmarks of AKI, making it less urgent.

Choice B reason: Blood pressure of 138/86 mm Hg and heart rate of 92 bpm are within normal ranges and not specific to AKI. While hypertension can occur in AKI due to fluid overload, these values do not strongly suggest AKI without other signs like oliguria or lab abnormalities.

Choice C reason: Cloudy urine with sediment and foul odor suggests a urinary tract infection, not necessarily AKI. Infections can coexist with AKI but are not diagnostic. AKI is characterized by reduced urine output and elevated creatinine, not primarily by urine appearance, making this finding less indicative.

Choice D reason: Urine output of 150 mL in 8 hours (450 mL/day) indicates oliguria, a key sign of AKI, where kidneys fail to filter adequately, reducing urine production. This can lead to fluid overload and toxin accumulation, necessitating urgent provider notification to evaluate and manage potential AKI complications like hyperkalemia.

A. It happens frequently, so just ignore it; they will stop B. Set firm limits and boundaries for the client C. Walk away and have someone else take care of the client D. Tell the client that you are going to report to the director of the unit

Correct Answer is B

Explanation

Choice A reason: Ignoring sexually aggressive behavior is unsafe and unprofessional, as it fails to address potential escalation or harm. Aggression may stem from impulsivity or mental health conditions, requiring intervention to ensure safety and maintain therapeutic boundaries, making this response inadequate and risky in a behavioral health setting.

Choice B reason: Setting firm limits and boundaries establishes clear expectations, reducing inappropriate behavior while maintaining safety. This approach addresses the client’s impulsivity or lack of control, common in mental health disorders, by reinforcing professional conduct and ensuring a therapeutic environment, making it the most effective and safe response.

Choice C reason: Walking away and delegating care avoids addressing the behavior, potentially escalating the client’s aggression or disrupting care continuity. It fails to establish boundaries, which are critical for managing behavioral issues in mental health settings, and may undermine the client’s trust in the therapeutic process, making it inappropriate.

Choice D reason: Reporting to the director without first addressing the behavior skips essential de-escalation steps. While reporting may be needed for persistent issues, immediate boundary-setting is more appropriate to manage aggression, maintain safety, and support therapeutic goals, making this response less effective as an initial action.

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A client diagnosed with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the client’s abdomen is increasing in girth. What is the nurse’s most appropriate action?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for an acutely ill client. Which assessment finding should prompt the nurse to inform the healthcare provider that the client may be exhibiting signs of acute kidney injury (AKI)?

Correct Answer is D

Explanation

A novice nurse is beginning work on a behavioral health unit and states to the preceptor, “What if I encounter a client who is sexually aggressive?” Which is the appropriate response by the preceptor?

Correct Answer is B

Explanation

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