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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

D. Vital sign measurements, including blood pressure, heart rate, respiratory rate, and temperature, are essential for assessing the client's hemodynamic stability and overall condition. A rigid abdomen with rebound tenderness suggests a potential surgical emergency, such as bowel perforation, which could lead to sepsis and hemodynamic instability. Therefore, obtaining vital sign measurements promptly will help determine the severity of the client's condition and guide further interventions.
A. Encouraging ambulation would not be appropriate in this situation because it could exacerbate the client's discomfort and potentially worsen any abdominal pain or tenderness. Ambulation is not the priority when a client presents with signs of a possible bowel perforation.
B. Measure capillary glucose level: While monitoring blood glucose levels is important, especially in clients receiving corticosteroid treatment, it is not the priority when the client is presenting with symptoms suggestive of a serious complication such as bowel perforation. Immediate assessment and intervention to address the abdominal rigidity and rebound tenderness are needed before other assessments can be performed.
C. While bloody stools are a common symptom of IBD exacerbation, the presence of a rigid abdomen with rebound tenderness suggests a more urgent issue, such as bowel perforation, that requires immediate attention. Monitoring for bloody stools should occur concurrently with assessing and managing the client's acute abdominal symptoms.

A. Use standard precautions and wear a mask B. Monitor the client's white blood cell count. C. Send wound drainage for culture and sensitivity. D. Explain the purpose of a low bacteria diet. E. Institute contact precautions for staff and visitors.

Correct Answer is ["A","C","E"]

Explanation

A. Standard precautions should always be followed when caring for any patient to prevent the transmission of infectious agents. Additionally, wearing a mask can provide further protection, especially if there is a risk of respiratory droplet transmission.
C. Culturing the wound drainage allows for the identification of the specific bacteria causing the infection, including whether it is methicillin-resistant Staphylococcus aureus (MRSA). Sensitivity testing helps determine which antibiotics are effective against the bacteria, guiding appropriate antibiotic therapy.
E. Contact precautions are necessary for preventing the transmission of MRSA to other patients, staff, and visitors. This includes wearing gloves and gowns when providing care, as well as ensuring proper hand hygiene practices. Visitors may also need to follow specific precautions to prevent the spread of infection.
B. While monitoring the client's white blood cell count may be important for assessing the body's response to infection, it is not specific to MRSA infection. MRSA infection is typically diagnosed based on clinical presentation and confirmed through laboratory tests such as wound cultures.
D. A low bacteria diet is not typically indicated for MRSA infection. MRSA is primarily treated with antibiotics, and dietary modifications are not a standard part of its management.

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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?

Nursing Test Bank

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