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.
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Related Questions
Correct Answer is C
Explanation
A. Incorrect. Collecting a sample of the effluent for culture and sensitivity testing may be necessary, but notifying the healthcare provider about the finding should be done first.
B. Incorrect. Stopping the exchange immediately may be necessary in some cases, but the nurse should first communicate the finding to the healthcare provider for further assessment and guidance.
C. Correct. Cloudy dialysate effluent may indicate peritonitis, an infection of the peritoneal cavity, which requires immediate attention and treatment by the healthcare provider.
D. Incorrect. Encouraging the client to perform another exchange without further assessment can potentially exacerbate any underlying issue causing the cloudy effluent.
Correct Answer is B
Explanation
A. Incorrect. Warming the dialysate fluid to body temperature before instilling it into the peritoneal cavity is a standard procedure in continuous ambulatory peritoneal dialysis (CAPD. .
B. Correct. Performing the exchanges in a clean, dry environment free from pets is crucial to prevent contamination and reduce the risk of infection during CAPD.
C. Incorrect. Using tap water to cleanse the catheter insertion site before the exchange is not recommended. The catheter exit site should be cleaned with an appropriate antiseptic solution as instructed by the healthcare provider.
D. Incorrect. While daily dressing changes are important, using sterile technique for catheter dressing changes may not be necessary, as the dressing does not directly contact the peritoneal cavity during CAPD exchanges.
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