A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?
Outflow obstruction.
Exit site infection.
Atelectasis
Peritonitis.
The Correct Answer is B
B. Redness, tenderness, and drainage around the catheter site are classic signs of an exit site infection in peritoneal dialysis. Exit site infections are a common complication of peritoneal dialysis and can lead to more serious complications, such as peritonitis, if not promptly treated. Preventing exit site infections through proper catheter care and hygiene is essential in peritoneal dialysis management.
A. While outflow obstruction can occur in peritoneal dialysis, it typically presents with symptoms such as poor drainage of dialysate fluid, abdominal discomfort, and a decrease in dialysis efficiency. The described findings of redness, tenderness, and drainage around the catheter site are more indicative of a localized issue rather than outflow obstruction.
C. Atelectasis refers to the collapse of a part or the entire lung. While it can occur in hospitalized patients, especially those with underlying respiratory conditions, the described findings are not indicative of atelectasis. Atelectasis typically presents with symptoms such as dyspnea, cough, and decreased breath sounds on auscultation.
D. Peritonitis is a severe complication of peritoneal dialysis characterized by inflammation and infection of the peritoneal lining. While redness, tenderness, and drainage around the catheter site may precede peritonitis, the focus of concern in this scenario is primarily on preventing exit site infection, which, if left untreated, can progress to peritonitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Complete restriction of physical activities is not necessary. The nurse should provide guidance on gradually resuming normal activities based on the healthcare provider's recommendations.
B. Incentive spirometer is not directly related to the management or recovery following TUNA for BPH. This device is typically used to improve lung function and prevent respiratory complications, which may not be a primary concern in this scenario.
C.While clients should monitor hematuria, the primary focus post-TUNA is on urinary output and function rather than just the color of the urine. Changes in hematuria color are important, but they may not directly correlate to urgent issues.
D. After TUNA, clients need to be vigilant about their urinary output because a decrease can indicate complications such as re-obstruction, which is a significant concern following the procedure. Monitoring urinary stream is essential for detecting potential issues early, making this the best choice for discharge instructions.
Correct Answer is C
Explanation
Choice A reason:This is incorrect because teaching the client to wear a mask, hand wash, and social distance is not the most important action for the nurse to take. These are preventive measures that should be followed by everyone, regardless of their COVID-19 status.
Choice Breason:This is incorrect because explaining to the client to inform others that they may have been potentially exposed in the last 14 days is not the most important action for the nurse to take. This is a moral and social responsibility that should be done as soon as possible, but it does not address the urgent need of isolating the client from potential sources of infection.
Choice Creason:This is correct because isolating the client from other clients, family, and healthcare workers not wearing proper PPE is the most important action for the nurse to take. This is to prevent transmission of COVID-19 to others who may be at risk of severe complications or death.
Choice Dreason:This is incorrect because reporting the COVID-19 result to the local health department according to CDC guidelines is not the most important action for the nurse to take. This is a legal and ethical obligation that should be done after confirming the diagnosis, but it does not have an immediate impact on the client's health or safety.
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