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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Hourly nursing assessments are important for monitoring safety in restraints but are not the primary legal requirement. Assessments ensure no physical harm, but psychiatric evaluation within one hour is mandated to confirm restraint necessity, making this option secondary in priority for immediate post-restraint protocol.
Choice B reason: Constant supervision may be used, but transitioning to video monitoring after one hour does not meet strict regulatory standards for restraints. Face-to-face psychiatric evaluation within one hour is required to assess ongoing need and ensure patient rights, making this option less accurate for legal compliance.
Choice C reason: Regulatory standards (e.g., CMS, Joint Commission) mandate a face-to-face evaluation by a psychiatrist within one hour of initiating restraints to assess necessity, safety, and alternatives. This ensures compliance with mental health laws, protects patient rights, and prevents overuse, making it the required action.
Choice D reason: Reviewing restraint appropriateness hourly is part of ongoing care but is not the primary requirement. A psychiatrist’s face-to-face evaluation within one hour takes precedence to ensure legal and ethical use, as it confirms the clinical justification for restraints, making this option secondary.
Correct Answer is D
Explanation
Choice A reason: Saying “I am not sure I follow you” seeks clarification, encouraging the patient to elaborate without dismissing their feelings. It fosters open communication, allowing the nurse to understand the patient’s concerns better, which supports therapeutic interaction and validates the patient’s emotional expression in a clinical setting.
Choice B reason: Noticing lip-biting acknowledges nonverbal cues, signaling the nurse’s attentiveness to the patient’s emotional state. This observation invites further discussion without judgment, promoting trust and validating the patient’s feelings, which is therapeutic and does not undermine or belittle their concerns in a mental health context.
Choice C reason: Stating “You appear tense” reflects observation of the patient’s emotional state, prompting exploration of underlying issues. It validates the patient’s feelings without dismissal, encouraging dialogue. This therapeutic approach supports emotional expression and does not belittle concerns, making it appropriate in a nurse-patient interaction.
Choice D reason: Saying “Everything will be alright” dismisses the patient’s concerns by offering false reassurance without addressing specific issues. This minimizes their emotional experience, potentially invalidating feelings and discouraging open communication, which can undermine trust and hinder therapeutic progress in managing mental health concerns.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.