A client on peritoneal dialysis is experiencing cloudy dialysate drainage. Which of the following actions should the nurse take first?
Document the finding and continue monitoring the client.
Administer an antibiotic medication.
Increase the dialysis exchange frequency.
Check the client's vital signs and assess for abdominal pain.
The Correct Answer is D
A) This statement is incorrect. Cloudy dialysate drainage may indicate infection or peritonitis, and the nurse should not simply document the finding and continue monitoring without further assessment.
B) This statement is incorrect. Administering an antibiotic medication without a definitive diagnosis is not appropriate. The nurse should assess the client further to determine the cause of the cloudy drainage.
C) This statement is incorrect. Increasing the dialysis exchange frequency would not address the issue of cloudy dialysate drainage and may not be indicated without a proper assessment.
D) This statement is correct. Cloudy dialysate drainage may indicate infection or peritonitis. The nurse should check the client's vital signs and assess for signs of abdominal pain or tenderness, as this requires immediate evaluation.
Nursing Test Bank
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Related Questions
Correct Answer is B
Explanation
A) This statement is incorrect. Monitoring hemoglobin levels is essential for clients with ESRD and during hemodialysis, but it is not directly related to the administration of heparin.
B) This statement is accurate. While a drop in platelet count is not uncommon during heparin administration, the nurse should closely monitor the client's platelet count to detect any significant changes or potential complications related to heparin-induced thrombocytopenia.
C) This statement is incorrect. Monitoring blood glucose levels is important, especially for clients with diabetes or those at risk of hypoglycemia during dialysis, but it is not specifically related to heparin administration.
D) This statement is incorrect. Monitoring blood urea nitrogen (BUN) levels is crucial for clients with ESRD, but it is not directly related to the administration of heparin during hemodialysis.
QUESTIONS
Correct Answer is C
Explanation
A) This statement is incorrect. Peritoneal dialysis does not use a machine to filter blood outside of the body; that description is characteristic of hemodialysis.
B) This statement is incorrect. Peritoneal dialysis does not involve the removal of the peritoneal membrane; instead, it uses the peritoneal membrane in the abdomen to filter waste.
C) This statement is accurate. Peritoneal dialysis uses the peritoneal membrane in the abdomen as a semipermeable membrane to filter waste products and excess fluids from the blood.
D) This statement is incorrect. Peritoneal dialysis does not require a catheter to be inserted into the bladder. Instead, it uses a catheter to infuse and drain dialysate into and out of the peritoneal cavity.
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